Improvements in end-of-life care with a protocol-based pathway for cancer patients dying in a Singapore hospital

<p><b>INTRODUCTION</b>More than half of all deaths in Singapore occur in hospitals. Little is known about the quality of care received by dying patients in hospitals. The Liverpool Care Pathway (LCP) provides a framework of providing good end-of-life care for dying patients and has been used with success in the United Kingdom (UK). In this study, we investigate whether adoption of a modified LCP in a Singapore hospital translated to better end-of-life care for cancer patients.</p><p><b>MATERIALS AND METHODS</b>The LCP was adapted and implemented as a pilot project on an oncology ward in Singapore General Hospital. A baseline review of 30 consecutive death records was performed, followed by a 4-month pilot and post-implementation audit of 30 consecutive patients on the adapted LCP.</p><p><b>RESULTS</b>Five types of end-of-life symptoms were analysed. There was only 1 uncontrolled symptom at death in the post-implementation group compared to 24 uncontrolled symptoms in the retrospective audit group. The prescription of breakthrough medications for symptom control increased from 21% in the retrospective audit group to 79% in the post-implementation group. Inappropriate monitoring was discontinued in 25 patients in the post-implementation group compared to none in the retrospective audit group. The documentation of resuscitation status and religion of the patient was improved, achieving full documentation in the post-implementation group.</p><p><b>CONCLUSION</b>This study shows promising results for improving end-of-life care in cancer patients with a protocol-based pathway in a Singapore hospital. Extension of this care pathway to other settings should be explored to maximise its benefits to patients dying from all causes in hospital.</p>

Where the elderly die: the influence of socio-demographic factors and cause of death on people dying at home

<p><b>INTRODUCTION</b>The place of death of the elderly has implications on the overall healthcare delivery system. The aim of this study is to describe where deaths of elderly occur in Singapore and to determine the association of socio-demographic characteristics and the causes of death on dying at home.</p><p><b>MATERIALS AND METHODS</b>Data of 10,399 Singapore resident decedents aged 65 years and above in 2006 were obtained from the national Registry of Births and Deaths. Distributions of socio-demographic characteristics and causes of death by place of death were analysed, and associations between socio-demographic characteristics and home death for major causes of death were assessed by logistic regression models controlling for age, gender and ethnic group.</p><p><b>RESULTS</b>Most elderly deaths occurred in hospitals (57%), followed by deaths at home (31%). The proportion of deaths at home increased with age while deaths in hospital declined with age. Significantly more elderly women died at home compared to men. Malay elderly had the highest proportion of home deaths (49%), and the lowest proportion of hospital deaths (47%). Elderly persons who died from stroke were most likely to die at home [odds ratio (OR) 2.8, 95% confidence interval (CI), 2.3-3.3] while those who died from lung and respiratory system diseases were less likely to die at home (OR, 0.7; 95% CI, 0.6-0.8).</p><p><b>CONCLUSION</b>Elderly people in Singapore die mainly in hospitals. About a third of them die at home. The proportion of decedents dying at home increased with age. Home deaths among the elderly are most likely in those aged 85 years and above, females, Malays, and those who die of stroke.</p>