Article Figures & Data
Figures
- Figure 1
Functional trajectories in the 12 months before start of hospice (N = 213).
Notes: The severity of disability is indicated by the mean number of disabled activities of daily living (basic, instrumental, and mobility). The solid lines indicate the observed trajectories, and the dashed lines indicate the predicted trajectories. Trajectories shown are unadjusted; only minor differences were apparent after adjustment for age and sex. The error bars indicate bootstrapped 95% CIs for the observed severity of disability. The average group membership probability for each group was greater than 0.9.
- Figure 2
Association between functional trajectory before hospice and overall survival after hospice admission (N = 213).
Notes: For each prehospice trajectory group, the product-limit survival function estimate is plotted by the Kaplan-Meier method. The median overall survival was 14 days; no significant difference in survival was observed across the trajectory groups (P = .79, log-rank test). The 26 (12.2%) participants who were still alive were censored at 180 days.
Tables
Diagnosis Category Patients, No. (%) ICD-9 Description ICD-9 Code(s) Cancer 74 (34.7) Malignant neoplasm 140–209 Uncertain or unspecified neoplasms 235–239 Neurodegenerative 45 (21.1) Mental disorders 290–319 Parkinson’s and other cerebral degenerations 330–332 Slow virus and prion disease of central nervous system 046 Cardiac 34 (16.0) Heart disease 410–429 Vascular 14 (6.6) Stroke 430–438 Aneurysm or aortic dissection 441–442 Respiratory 11 (5.2) Pulmonary diseases 490–519 Respiratory abnormality not elsewhere classified 786.9 Other organ failure 15 (7.0) Gastrointestinal and liver disease 530–539, 555–579 Renal disease 580–589 Frailty/debility 20 (9.4) Adult failure to thrive 783.7 Debility not otherwise specified 799.3 -
ICD-9 = International Classification of Diseases, 9th Revision.
Note: As described in the Methods, the primary classification scheme was based on ICD-9 diagnosis codes. Ten decedents who did not fit this scheme were classified by review of preceding hospital discharge records: 2 cancer, 1 neurodegenerative, 3 cardiac, 2 other organ failure, and 2 frailty/debility.
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- Table 2
Patient Characteristics by Functional Trajectory Before Hospice and Hospice Admission Diagnosis
Characteristic Patients, No. (%) Age, Mean (SD), ya Female Sex, No. (%) Non-Hispanic White, No. (%) <12 Years’ Education, No. (%) Chronic Conditions, Mean (SD), No.b Overall 213 (100) 86.4 (5.8) 138 (64.8) 192 (90.1) 79 (37.1) 2.5 (1.3) Functional trajectoryc Late decline 23 (10.8) 82.0 (6.2) 12 (52.2) 22 (95.7) 4 (17.4) 2.4 (1.3) Accelerated 23 (10.8) 83.9 (4.9) 13 (56.5) 22 (95.7) 6 (26.1) 2.5 (1.2) Moderate 45 (21.1) 83.9 (5.1) 26 (57.8) 38 (84.4) 17 (37.8) 2.6 (1.2) Progressively severe 53 (24.9) 88.7 (5.1) 37 (69.8) 49 (92.5) 25 (47.2) 2.5 (1.2) Persistently severe 69 (32.4) 88.6 (5.0) 50 (72.5) 61 (88.4) 27 (39.1) 2.4 (1.4) Admission diagnosisd Cancer 74 (34.7) 83.6 (5.9) 42 (56.7) 67 (90.5) 24 (32.4) 2.7 (1.3) Neurodegenerative 45 (21.1) 87.7 (5.1) 30 (66.7) 38 (84.4) 17 (37.8) 2.0 (1.1) Cardiac 34 (16.0) 87.9 (5.6) 19 (55.9) 32 (94.1) 17 (50.0) 2.7 (1.2) Frailty/debility 20 (9.4) 90.9 (4.3) 15 (75.0) 19 (95.0) 8 (40.0) 2.3 (1.2) Other organ failure 15 (7.0) 87.7 (4.7) 12 (80.0) 15 (100) 5 (33.3) 2.8 (1.5) Vascular 14 (6.6) 85.0 (5.3) 11 (78.6) 11 (78.6) 5 (35.7) 2.0 (1.5) Respiratory 11 (5.2) 87.1 (3.8) 9 (81.8) 10 (90.9) 3 (27.3) 3.2 (1.3) -
↵a Age was measured at the start of the trajectories.
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↵b Average based on 9 physician-diagnosed, patient-reported conditions: diabetes, hypertension, arthritis, cancer, chronic lung disease, congestive heart failure, myocardial infarction, hip fracture, and stroke.
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↵c The 95% CIs for the group membership frequencies, based on 1,000 bootstrap samples, were as follows: late decline, 5.6% to 16.0%; accelerated, 4.2% to 17.6%; moderate, 13.4% to 28.2%; progressively severe, 17.4% to 32.4%; and persistently severe, 23.9% to 42.3%.
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↵d As defined in Table 1.
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Functional Trajectory Cancer, No. (%) Neurodegenerative, No. (%) Cardiac, No. (%) Vascular, No. (%) Respiratory, No. (%) Other Organ Failure, No. (%) Frailty/Debility, No. (%) Total, No. (%) Late decline 9 (25.7) 1 (2.2) 0 (0.0) 1 (7.14) 2 (18.2) 0 (0.0) 0 (0.0) 23 (10.8) Accelerated 2 (16.2) 0 (0.0) 4 (11.8) 4 (28.6) 0 (0.0) 1 (6.7) 2 (10.0) 23 (10.8) Moderate 2 (29.7) 5 (11.1) 7 (20.6) 3 (21.4) 0 (0.0) 5 (33.3) 3 (15.0) 45 (21.1) Progressively severe 5 (20.3) 6 (13.3) 16 (47.1) 3 (21.4) 6 (54.6) 3 (20.0) 4 (20.0) 53 (24.9) Persistently severe 6 (8.1) 33 (73.3) 7 (20.6) 3 (21.4) 3 (27.3) 6 (40.0) 11 (55.0) 69 (32.4) -
Note: Percentages may not add up to 100 because of rounding.
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- Table 4
Multivariate Associations of Functional Trajectories Before Hospice With Outcomes in the Month After Hospice Admission
All Participants (N = 210): Alive and Not Completely Disabled Surviving Participants (n = 95): Not Completely Disabled Functional Trajectory With Outcome/At Risk, Nos. Adjusted OR (95% CI) With Outcome/At Risk, Nos. Adjusted OR (95% CI) Late decline 4/23 3.5 (0.8–23.3) 4/10 3.9 (0.8–32.2) Accelerated 5/23 4.4 (0.7–27.1) 5/13 4.4 (0.6–52.8) Moderate 11/44 5.5 (1.9–35.9) 11/18 10.5 (3.3–134.2) Progressively severe 4/53 1.3 (0.3–9.9) 4/21 1.7 (0.4–13.6) Persistently severe 4/67 Ref 4/33 Ref -
OR = odds ratio; Ref = reference group.
Note: Three participants (1.4%) who had withdrawn from the study before hospice admission were omitted from these analyses. Results from the logistic regression models are adjusted for age and sex.
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Supplemental Figures 1-2
Files in this Data Supplement:
- Supplemental data: Figures 1-2 - PDF file, 2 pages + cover
The Article in Brief
Functional Trajectories in the Year Before Hospice
Thomas M. Gill , and colleagues
Background Because of restrictions on hospice (end of life) care and confusion between hospice and palliative care (treatment of stress and pain during serious illness), many older persons do not receive hospice or palliative care near the end of life. This can burden caregivers and increase patients' suffering. This study examines the course, or trajectory, of disability in older patients in the year before hospice.
What This Study Found The study found five trajectories, representing worsening disability, among patients 70 years or older who were later enrolled in hospice. Participants with neurodegenerative disease had the worst functional trajectory, whereas those with a cancer diagnosis had the most favorable. Nearly 60 percent of the study sample had progressively or persistently severe disability during the year before hospice. The median survival in hospice was only 14 days and did not differ significantly by functional trajectory.
Implications
- Late admission to hospice, as shown by patients' short survival, coupled with high levels of severe disability before hospice indicate there are potential unmet palliative care needs for many at the end of life.
