Do Caregivers Have an Effect on Extended Hospitalization in Patient-Fallowed Palliative Care Center? A Study from Turkey.

doi:10.21203/rs.3.rs-3468911/v2

Objective: Since palliative care clinics are clinics that strive to solve the pain caused by the disease as well as other physical and psychological symptoms and social problems as a caregiver burden, the length of stay becomes important in our clinics with high demand from patients.

One of the purposes of palliative care centers is to evaluate the patient for discharge, to provide devices that the patient needs at home or in a nursing home, and to provide caregivers with care and device usage training. We aimed to investigate whether the length of stay is caused by the caregivers as well as clinical conditions.

Material and Methods: In this study, we retrospectively investigated the days of hospitalization of 915 patients followed in a palliative care center and the factors that prolong hospitalization in patients with extended hospitalization.

Results: The average length of stay of the patients was found to be 15.65±11.43 days. Hospitalization longer than 28 days was found to be 97(10.60%) patients. The most common reason for extended hospitalization was the reluctance of caregivers to discuss discharge in 47 (48.45%) patients. The second most frequent discharge was delayed in 25 (25.8%) patients due to clinical instability. 23(23.71%). A significant relationship was detected between length of stay and TPN nutrition. A significant relationship was detected between patients with cancer (P:0.042) and coronary artery disease (P<0.01) on extended stay.

Conclusion: With the aging of the world population and the improvement of health care services, the need for palliative care is increasing daily. In order to use resources efficiently, there is a need to optimize the length of stay in palliative care with a multidisciplinary approach.

Trial registration

This study registered retrospectively.

Palliative care

Extended Hospitality

caregivers

The impact of palliative care, which includes symptom management that impairs the quality of life at the end of life, is a relatively new formation that has been developing continuously for the last 30 years. As the elderly population in societies increases daily and their importance is understood, its popularity is increasing among health professionals and caregivers[1]. Since palliative care centers are clinics that struggle to solve the pain caused by the disease, as well as other physical and psychological symptoms and social problems, length of stay becomes important in our clinics, which are in high demand. One of the purposes of palliative care centers is to evaluate the patient for discharge, to provide devices that the patient needs at home or in a nursing home, and to provide caregivers with care and device usage training[2]. Palliative care is a holistic approach in which caregivers, as well as health professionals, participate in patient care, but there are still very limited studies investigating the caregiver burden and their effects on the length of stay in palliative care in Turkey[3].

The biggest challenge in palliative care research is the difficulty of conducting randomized controlled trials. This difficulty is due to the wide range of patients and the sociological and ethical issues involved, such as withdrawal and withholding [4,5].

Although there is a concept such as extended hospitalization in intensive care units, extended hospitalization for palliative care centers is still a matter of debate[4]. Although it is known that palliative care is cost-effective, it is also known that it prolongs the length of stay, but the reasons for the extended stay remain unclear [5].

In this study, we aimed to investigate the data of the patients who were followed up as inpatients in our palliative care center, their discharge status, and the factors affecting the extended hospitalization day.

This study is cross-sectional and retrospective. The data of patients aged 18 and over who were followed consecutively at Ankara Bilkent City Hospital internal medicine clinic, Palliative Care Center between January 2020 and October 2023 were taken from the hospital's electronic database. Those with more than one hospitalization and those with hospitalizations other than their first hospitalization were excluded from the study.

Age, gender, diagnosis, major morbidities (cancer, Alzheimer's, cerebrovascular disease), comorbid conditions such as; congestive heart failure, hypertension, diabetes mellitus, coronary artery disease, chronic kidney failure medications used, nutrition style, caregiver status, tracheostomy were noted all patients. Conditions, pressure ulcer conditions, pain scores, painkiller use, anxiolytic use, length of stay, discharge status were noted. We consider the 28 days as sufficient time for caregivers to develop their ability to care for the patient and to adapt to the care and the patient's symptoms. Patients are evaluated for discharge at the end of the 28th day at the latest. Those with a length of stay of 28 days or more were considered as extended hospitalization in the patient group with extended hospitalization, factors that extended the length of stay were obtained from the hospital data processing center, nurse and doctor observation forms.

The nutritional status of the patients at the time of admission to our service was recorded with the nutritional risk score (NRS 2002) form. According to the NRS 2002 score, patients with a score of ≥3 were interpreted as a malnutrition risk group. Enteral or type-parenteral-type feeding routes of the patients were recorded. It was determined that he was fed via nasogastric (NG), percutaneous gastrostomy (PEG), and percutaneous jejunostomy (PEJ)[6].

Breden risk assessment scale was used for pressure ulcer evaluation immediately after the patients were admitted to the palliative care center. According to this scale, ≤12 points were considered high risk, 13-14 points were considered risky, and 15-18 points were considered low risk. Preventive practices for pressure ulcers were reviewed in all patients. Pressure ulcer staging was performed[7,8].

Pain was determined using the visual pain scale (VAS) in patients who could be contacted for pain scores, and the behavioral pain score (DAS) in other patients. At the same time, the analgesics used by patients with pain were recorded[9,10].

For this study, local ethics committee approval numbered E1-23-4076 was received from Ankara City Hospital Ethics Committee 1. The principles of the Declaration of Helsinki were followed.

Statistical Method

The data obtained from the Hospital Information Management Systems (HIMS) notes, and nurse, dietitian, and doctor daily evaluations were entered into IBM SPSS Statistics for Windows 26.0 (IBM Corp., Armonk, NY, USA). Normality distributions of the data were made. Descriptive analyses were performed. Normally distributed data were compared using the Spearman correlation method. P <0.05 was considered statistically significant. In the presence of two variables, an analysis of T-tests was used. In the presence of more than two variables, analysis of variance (ANOVA) was used.

915 consecutively followed-up patients from January 2020 to September 2023 were included in the study. The average age of the patients was found to be 71.77±15.22. Among the patients, 478 (52.24%) were female. Eastern Cooperative Oncology Group (ECOG) performance scales of all patients were 3-4. The first morbidity in patients was cerebrovascular diseases with 345 of 37.70% of patients. In the second place, 294 (32.13%) were accompanied by end-stage cancer. The third most common disease was advanced-stage Alzheimer’s disease (27.54%). The majority of diseases that caused the patients to be admitted to the palliative care center are given in Table 1. 673 (73.55%) of the patients were transferred from intensive care units to the palliative care center. 190 (20.77%) patients were transferred from inpatient clinics. 52 (5.68%) patients were admitted to the palliative care center upon the application of the home health unit and the patient's relatives. Mortality was observed in 282 (30.82%) patients from the entire patient population during hospitalization. A significantly higher mortality was observed in the group with prolonged hospital stay (P:0.02). Nutritional problems were the most frequently observed during admission, and pain was the third most common in 304 (33.22%) patients. When the patients were evaluated in terms of feeding methods, 484(52.90%) were fed orally, the second most common was 209 (22.84%) patients who received total parenteral nutrition (TPN) during hospitalization. The third most common was 161 (17.60%) patients who received tube feeding (TPN). A significant relationship was detected between TPN use and cancer and age (P<0.01). Low-potency tramadol/oxycodone was the most preferred painkiller in 211 (23.06%) patients with pain. The use of morphine was preferred in 12(1.31%) patients. In terms of pressure ulcers, all patients received <12 points according to the Braden risk score. While 18 (18.56%) patients in the group with extended hospitalization had at least stage 1 pressure ulcers, pressure ulcers were detected in 175 (21.39%) patients in the group without extended hospitalization, and there was no significant difference between them (P: 0.518). Our rate of delirium, which contributes to the deterioration of the general condition of inpatients, was found to be193 (21.10%). Anxiolytics were preferred in 216 (23.61%) patients during their hospitalization. The most preferred anxiolytic drug was quetiapine, with the first frequency in patients 124(13,55%) haloperidol, with the 67(7.32%) second frequency in patients. Lorazepam was used in 25 (2.73%) patients. No significant difference was found between extended stay and anxiolytic use (p>0.05). It was determined that 481 (52.57%) of the patients were relatives and nine patients were orphans. The demographic data of the patients are shown in Table 2. The average length of stay of the patients was found to be 15.65±11.43 days. The rate of hospitalization longer than 28 days was found to be 10.60% (97). The most common reason for extended hospitalization was the reluctance of caregivers to discuss discharge in 47 (48.45%) patients. The second most frequent discharge was delayed in 25 (25.77%) patients due to clinical instability. Table 3 shows the factors that cause a prolonged stay. 23(23.71%). A significant difference was detected between the length of stay and the presence of tracheostomy. (P<0.05). A significant relationship was detected between length of stay and TPN and nutrition. A significant relationship was detected between patients with comorbid cancer (P:0.042) and coronary artery disease (P<0.01) and extended stay.

Today, palliative care deals with many different modalities, such as increasing the functions of patients, identifying and meeting all their social and physical needs, and training and supporting caregivers, in addition to end of life care. Although there are studies on the length of stay in palliative care in Turkey, all reasons for an extended stay have been considered in a medical situation. To our knowledge, there is no study investigating the effect of caregiver in Turkey.

In this study, the most common co-morbidity during hospitalization was cerebrovascular disease. The second most common was cancer patients, who form the basis of palliative care. Cerebrovascular disease was found to be compatible with the study conducted by Yürüyen et al. from Turkey. Even though cancer patients were the second most common reason for hospitalization, we found a significant relationship with the extended stay. The reason for this may be that even if patients want to die at home, they want their relatives to be in the hospital environment[11].

In addition to inpatient services, patients' relatives can apply to palliative care centers through home care services or at their request. In our study, we found that the majority of patients admitted to the palliative care center were from intensive care units. In the study conducted by Miniksar et al., home health services come first in the applications. This data may seem contradictory to our study. Still, due to the high number of intensive care beds in our hospital, which serves as a 3rd step, outpatients can be transferred to other palliative care centers with home care services[12]. We have cooperation with intensive care teams for the effective use of intensive care units in our 3600-bed hospital complex [4].

Indications for admission to palliative care may vary depending on the heterogeneity of patients, or there may be more than one indication. In our study, the most common reasons for hospitalization were poor general condition and nutritional problems. In the study conducted by Dinçer et al., nutritional problems were the most common reason for hospitalization[13]. Even though nutrition is still a controversial issue in palliative care, for Turkey sociodemographically, nutrition is at least as important as the pain perceived by caregivers in palliative care. There is even a dialogue between healthcare professionals and caregivers: 'Sir, this patient does not eat or drink, let's stay in the hospital a little longer.' The most common form of nutrition in our study was oral nutrition. The factor prolonging the hospital stay was determined to be the patient receiving total parenteral nutrition. It is similar to the study conducted by Yürüyen et al.

Pain is the main focus of palliative care. In our study, pain was the third most common symptom upon admission. Since pain is a subjective symptom, pain is tried to be understood using different methods. The most preferred painkillers in patients with pain were low-potency painkillers such as oxycodone and tramadol. The World Health Organization has also recommended the use of low-potency analgesics in pain palliation, followed by the use of high-potency ones [14]. According to a study conducted in Slovenia, opioid use varies widely in European countries. Even though our opioid use is not yet at the desired levels, it does not seem to be related to the length of stay. The biggest reason for this is that specialists are concerned that patients will become addicted in our country [15].

We see that in patients with accompanying symptoms such as delirium and anxiety, the most common use is quetiapine followed by haloperidol. Delirium is a hyperactive or hypoactive complex syndrome that has a wide range of symptoms and findings and is seen at very variable frequencies in hospitalized patients. In addition to nonpharmacological measures, pharmacological treatments are frequently needed to prevent delirium in patients. In pharmacological treatments, haloperidol, atypical antipsychotics, as well as benzodiazepines can be used. We believe that haloperidol is the second most preferred drug due to its side effect profile. The use of benzodiazepines has been much reduced because they can cause delirium to become more severe[16,17].

Palliative care is a complex structure that includes doctors, nurses, other healthcare professionals, as well as caregivers. Caregivers are included in the system to determine all the needs of the patients, to provide optimal care, to determine the needs of the caregivers, and to support the patient psychosocially before the patient's death and during the mourning period. Caregivers may be relatives or provide paid or volunteer services. Unfortunately, we did not have any volunteer caregivers in our study[18]. In our study, the first factor that affected the prolongation of hospitalization was the caregiver's desire for an extended hospitalization and their desire to extend the hospitalization as a result of not feeling competent in care. Palliative care Inclusion of caregivers in the holistic care approach represents a fundamental approach. However, we cannot think that the caregiver burden is adequately understood even by palliative care center teams. Because clinicians often think patient-oriented, the medical literacy and sociocultural needs of caregivers are often ignored [19]. The second factor for extended hospitalization is the patient's inability to be discharged due to unstable conditions. These patients may choose to die in the hospital or by the joint decision of the clinician and caregivers to let the death occur in the hospital[18]. The third factor that extended hospitalization was infections. In palliative care, it is still a matter of debate which treatments will be given and how much, but since there is no withdrawal or withholding in Turkey, the infection status of the patients cannot be ignored. With expert opinion, infections complete the optimal antibiotic days. This situation was one of the reasons that extended the hospitalization of patients [20,21].

Limitations of our study: Since our study was single-center and retrospective, we could not reach the caregivers' thoughts, concerns and results regarding the prolongation of hospitalization and discharge. Palliative care requires different approaches due to many different modalities. It is necessary to conduct multi-center prospective studies on palliative care, length of stay and caregivers. Moreover, in order to understand the burden of caregivers, national programs are needed to provide necessary training to health professionals and to support caregivers' needs and sociocultural aspects.

With the aging of the world population and the improvement of health care services, the need for palliative care is increasing day by day. In order to use resources efficiently, there is a need to optimize the length of stay in palliative care with a multidisciplinary approach. New prospective studies are needed on home palliative care models.

Authorship Contributions: Concept: N Y Ç, RB, Design: N Y Ç, RB, Supervision: Resources: NYÇ Materials: NYÇ, Data Collection And/or Processing: NYÇ, RB, Analysis And/or Interpretation: NYÇ, RB, Literature Search: NYÇ, RB, Writing Manuscript: NYÇ, Critical Review: NYÇ, RB.

Peer review: Externally peer-reviewed.

Financial Disclosure: The authors declared that this study has received no financial support.

Conflict of interest: No conflicts of interest were declared by the authors.

Consent for Publication: Not applicable.

Ethical Approval and Consent to Participate: This study was approved by Ankara Bilkent City Hospital Ethical 1 committee (Number: E1-23-4076, Date:04/10/2023). Since the study was designed retrospectively, Ankara Bilkent City Hospital Ethical 1 committee eliminated the need to obtain an informed consent form. The authors declared that this study is in accordance with the Declaration of Helsinki.

Author Information: Nuray Yılmaz Çakmak [email protected]

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	Length of Stay >28 Days N %		Length of Stay <28 Days N %		Total	%	P
Cerebrovascular disease	27/97	27,84%	318/818	38,88%	345	37,70%	0,034
Cancer (End- stage)	40/97	41,24%	254/818	31,05%	294	32,13%	0,042
Alzheimer's Disease (Advanced-stage )	23/97	23,71%	229/818	28,00%	252	27,54%	0,372

Table 1. The majority of diseases that caused the patients to be admitted to the palliative care center.

	Length of Stay>28 Days N%		Length of Stay<28days N%		Total	%	P
Gender(female)	50/97	51,55%	428/818	52,32%	478	52,24%	0,885
Diabetes mellitus	14/97	14,43%	71/818	8,68%	85	9,29%	0,650
Hypertension	13/97	13,40%	109/818	13,33%	122	13,33%	0,983
Coronary artery disease	23/97	23,71%	64/818	7,82%	87	9,51%	<0,01
Chronic renal failure	5/97	5,15%	38/818	4,65%	43	4,70%	0,823
Congestive heart failure	8/97	8,25%	36/818	4,40%	44	4,81%	0,094
Nutrition
Orally	52/97	53,61%	432/818	52,81%	484	52,90%	0,882
Percutan gastrostomy	14/97	14,43%	147/818	17,97%	161	17,60%	0,388
TPN	19/97	19,59%	190/818	23,23%	209	22,84%	0,42
Tracheostomy	15/97	15,46%	5/818	0,61%	20	2,19%	<0,01
Pressure ulcer	18/97	18,56%	175/818	21,39%	193	21,09%	0,518
Conditions
Pain	39/97	40,21%	265/818	32,40%	304	33,22%	0,123
General condition disorder	43/97	44,33%	438/818	53,55%	481	52,57%	0,086
Oral intake disorder	43/97	44,33%	440/818	53,79%	483	52,79%	0,78
Nonsurvivors	46/97	47,42%	236/818	28,85%	282	30,82%	0,02
Pain killer					463	50,60%
Paracetamol	17/68	25,00%	133/395	33,67%	150	16,39%	0,04
NSAID/steroid	0/68	0,00%	8/395	2,03%	8	0,87%
Tramadol/Oxycodone	33/68	48,53%	178/395	45,06%	211	23,06%	0,39
Fentanyl	13/68	19,12%	69/395	17,47%	82	8,96%	0,07
Morphine	5/68	7,35%	7/395	1,77%	12	1,31%	<0,01
Anxiolytic use					216	23,61%
Quetiapine	20/42	47,62%	104/174	59,77%	124	13,55%	0,05
Haloperidol	16/42	38,10%	51/174	29,31%	67	7,32%	0,06
Lorazepam	6/42	14,29%	19/174	10,92%	25	2,73%	0,05
Caregiver					915	100,00%	0,53
Relatives	46/97	47,42%	435/818	53,18%	481	52,57%	0,05
Salary caregiver	51/97	52,58%	380/818	46,45%	431	47,10%	0,05
No caregiver	0/97	0,00%	3/818	0,37%	3	0,33%

Table 2. The demographic data of the patients.

	N	%
Using antibiotics for infections	23	23,71
Caregivers don't want discharge	47	48,45
Waiting for the device supply	2	2,06
Unstable clinics	25	25,77
Total	97	100

Table 3. The factors that cause a prolonged stay.

The authors declare no competing interests.

supplemanterymaterial.docx

Do Caregivers Have an Effect on Extended Hospitalization in Patient-Fallowed Palliative Care Center? A Study from Turkey.

Status:

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Abstract

INTRODUCTION

MATERIAL AND METHOD

RESULTS

DISCUSSION

CONCLUSION

DECLARATIONS

REFERENCES

Tables

Additional Declarations

Supplementary Files

Status:

Version 2