Deaths at home, area-based deprivation and the effect of the Covid-19 pandemic: An analysis of mortality data across four nations.

BACKGROUND: The number and proportion of home deaths in the UK increased during the Covid-19 pandemic. It is not known whether these changes were experienced disproportionately by people from different socioeconomic groups. AIM: To examine the association between home death and socioeconomic position during the Covid-19 pandemic, and how this changed between 2019 and 2020. DESIGN: Retrospective cohort study using population-based individual-level mortality data. SETTING/PARTICIPANTS: All registered deaths in England, Wales, Scotland and Northern Ireland. The proportion of home deaths between 28th March and 31st December 2020 was compared with the same period in 2019. We used Poisson regression models to evaluate the association between decedent's area-based level of deprivation and risk of home death, as well as the interaction between deprivation and year of death, for each nation separately. RESULTS: Between the 28th March and 31st December 2020, 409,718 deaths were recorded in England, 46,372 in Scotland, 26,410 in Wales and 13,404 in Northern Ireland. All four nations showed an increase in the adjusted proportion of home deaths between 2019 and 2020, ranging from 21 to 28%. This increase was lowest for people living in the most deprived areas in all nations, with evidence of a deprivation gradient in England. CONCLUSIONS: The Covid-19 pandemic exacerbated a previously described socioeconomic inequality in place of death in the UK. Further research to understand the reasons for this change and if this inequality has been sustained is needed.

Ethnic Differences in Cancer Deaths at Home before and during Pandemic

Introduction Place of death is a metric used for planning and monitoring palliative care (PC). The COVID-19 pandemic has seen a significant increase in cancer deaths at home. Aims To determine whether pandemic increases in the percentage of cancer deaths at home differ by ethnic group Methods Data source: death registrations in England, 2018 to 2021 with underlying cause of death cancer (ICD-10 C00-C97). Ethnic group derived from linked hospital episode data. The age and deprivation distribution across ethnic groups varies and each has a strong independent effect on place of death. so, calculated percentage deaths at home were standardised by these factors to make them comparable. Analysis concentrated on the largest ethnic groups: White, Asian/Asian British (Asian), and Black/African/ Caribbean/Black British (Black). Comparisons were made between time periods by analysis of the ratio of percentages 2020-2021 (COVID-19 Pandemic) vs 2018-2019 (Baseline). Results For each ethnic group the age-standardised percentage of cancer deaths at home significantly increased (P < 0.05) from 2018-2019 to 2020-2021 . Asian: 33.5%, 47.5% . Black: 28.8%, 39.0% . White: 30.7%, 41.2% The ratio of standardised percentage of deaths at home (95% CI) was . Asian: 1.42 (1.36,1.48 ) . Black: 1.35 (1.27, 1.44) . White 1.34 (1.33, 1.35) Conclusions Cancer deaths at home increased by > 10 percentage points during the pandemic for Asians, Blacks and Whites. Significant differences between ethnic groups before the pandemic (2018-19) persisted with Asians more likely than Whites, and Blacks less likely than Whites to die at home. The largest increase was for Asians, the group with the highest pre-pandemic home deaths. Impact These ethnic differences merit investigation regarding cultural preferences, access issues and quality of PC experience. Community health and PC teams need additional resources and training in culturally sensitive care to support the increased number of ethnically diverse cancer patients dying at home.

European Cancer Summit 2022 submission for Special Network: Impact of the Covid-19 Pandemic on CancerImpact of the COVID-19 Pandemic on Cancer Surgery and Cancer Mortality in England

Background: During the pandemic there has been an impact on the number of patients entering the cancer pathway, because of changes in patients presenting and GP referral behaviours. The aim was to understand whether different groups in our society have been disproportionately affected by the pandemic in terms of the care they have received for their cancer. Method(s): The study looked specifically at elective admissions from the Hospital Episode Statistics data for all cancers combined and separately for breast, bowel, lung, and prostate cancers to investigate the number of patients admitted for cancer surgery over time. The ONS Mortality Dataset was used to investigate the place of death for patients who had died from cancer. Mortality rates were calculated to identify whether there was a rise in in-hospital mortality during the pandemic. Deaths were defined as an in-hospital death for a patient admitted with a primary diagnosis of cancer. Age-standardised mortality rates were created across the last five years, broken down by cancer type, sex and deprivation quintile. Result(s): The analysis shows a decrease in patients undergoing surgery at the start of the pandemic for all demographic groups. At the start of the pandemic, the largest decreases for all cancers combined by ethnicity could be seen in White (42.6%) and Asian or Asian British (44.6%). While by age, the largest decrease was seen in women aged 40-49. For lung cancer surgery, there were differences by deprivation quintile during the recovery period, showing a 42.0% increase in the least deprived compared to a 27.6% increase in the most deprived. However, changes at the beginning of the pandemic were similar across all quintiles. Age standardised mortality rates showed an increase in in-hospital deaths following the start of the pandemic. Conclusion(s): While we know that there are inequalities in access to cancer surgery, particularly by age, for the most part, the results of our analysis indicate that the recovery period of the COVID-19 pandemic has not exacerbated these inequalities. However, it is difficult to understand the extent to which any variation in access to cancer services is unwarranted.Copyright © 2023

The effect of integrated palliative care on quality of life and acute healthcare use in patients with COPD - results of the COMPASSION study

Introduction: Patients with advanced COPD experience a low quality of life (QoL). In oncological patients, palliative care improves QoL and reduces healthcare use. Whether this also applies to patients with COPD is not yet known. Therefore, in a cluster randomized controlled trial, we assessed the effectiveness of integrated palliative care on QoL and acute healthcare use of patients with COPD. Method(s): Eight hospital regions were randomized. Healthcare providers of intervention regions were trained in identification of palliative patients, multidimensional assessment, advance care planning and care coordination. Patients were identified using the ProPal-COPD tool. Questionnaires were completed by patients at baseline, after 3 and 6 months, and medical record assessment after 12 months. Primary outcome was QoL (FACIT-Pal). Secondary Outcomes: spiritual wellbeing, health-related QoL, anxiety/depression, acute healthcare use and place of death. Generalized linear modeling was used to adjust for baseline values and account for clustering by region. Result(s): Of 222 patients enrolled, 100 completed the questionnaire at 6 months. Intention to treat analysis showed no statistically significant effect on primary and secondary wellbeing outcomes. In the intervention group, the number of ICU admissions was lower (OR=0.212;p=0.047) and there was a trend for fewer hospitalizations (IRR=0.690;p=0.068). Discussion(s): We found no evidence that palliative care improves QoL in patients with COPD, but it can potentially reduce acute healthcare use. A low recruitment rate due to COVID-19, high loss to follow up and implementation failure have to be taken into account.

How people with intellectual disability are dying and implications for quality care

The characteristics of quality end-of-life care for people with intellectual disability are becoming increasingly clear. The research also shows the urgent and growing need for care, for an ageing population with increased incidence of life-limiting illnesses requiring often extended periods of care. A necessary first step to providing quality end-of-life care is to understand the conditions under which this group currently experiences death. This chapters uses the international literature to offer a picture about the current patterns of death, including death causes, age at and place of death, anticipated and potentially avoidable deaths, and deaths during the COVID-19 pandemic. Throughout, comparisons are made to the general population. Reflection questions to translate research to practice are given, as well as practical resources. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

[Trends in place of death for nursing home residents in an urban district during the COVID-19 pandemic: An analysis of death registry data]. / Entwicklung der Sterbeorte von Pflegeheimbewohnern in einem städtischen Versorgungsbereich während der COVID-19-Pandemie ­ eine Auswertung von Daten des Sterberegisters.

BACKGROUND: The nursing home is a common place of death; however, little is known about the place of death with respect to the people living there. Was there a difference in the frequencies of the places of death of nursing home residents in an urban district and in the individual facilities before and during the COVID-19 pandemic? METHODS: Full survey of deaths by retrospective analysis of death registry data from the years 2018 to 2021. RESULTS: Over the four-year period 14,598 people died, with 3,288 (22.5%) being residents of 31 different nursing homes. Over the reference period before the pandemic (March 1, 2018 to December 31, 2019) 1,485 nursing home residents died: 620 (41.8%) in hospital, 863 (58.1%) in a nursing home. During the pandemic period (March 1, 2020 to December 31, 2021) 1,475 death were registered: 574 (38.9%) in hospital and 891 (60.4%) in a nursing home. The mean age over the reference period was 86.5 years (±8,6; median 88.4; 47.9 to 106.2), in the pandemic period it was 86.7 years (±8,5; median 87.9; 43.7 to 111.7). Before the pandemic 1,006 deaths (67.7%) occurred in females, during the pandemic it was 969 (65.7%). The relative risk (RR) as a measure for the increase in the probabilty for an "in-hospital" death during the pandemic period was 0.94. In different facilities, the number of deaths per bed during the reference and the pandemic period varied between 0.26 and 0.98, and the RR from 0.48 to 1.61. DISCUSSION: For all nursing home residents, the frequency of deaths was not increasing and no shift towards an "in-hospital" death was observed. Several nursing homes revealed substantial differences and opposing trends. The strength and the type of effects of facility-related circumstances remain unclear.

'The beauty and the less beautiful': exploring the meanings of dying at 'home' among community and practitioner representatives and advocates across Canada.

Background: Significant structural and normative pressures privilege the ideal of dying at home in Canada. At the same time, the social complexities and meanings associated with dying in particular locations remain critically unexamined. Objective: The aim of this study is to explore how diverse community members, including health and social care stakeholders, talk about preferences for locations of dying, with a particular focus on meanings of dying at home. Design: Semi-structured virtual interviews were conducted with 24 community and practitioner representatives and advocates across Canada during the Covid-19 pandemic. This included compassionate community advocates, palliative care professionals and volunteers, bereaved carers, and members of queer, rural, and immigrant communities. Participants were asked about their own preferences for location of dying and elaborated on these aspects with regard to their client population or community group. Results: Our analysis illuminates how meanings of dying at home are connected to previous experiences and perceptions of institutional care. As such, participants' perspectives are often framed as a rejection of institutional care. Dying at home also often signals potential for preserving ontological security and relational connection in the face of life-threatening illness. However, participants' expertise simultaneously informs a sense that dying at home is often unattainable. At times, this awareness underpins interpretations of both preferences and choices as contingent on considerations of the nature and type of illness, concerns about impacts on families, and available resources. Conclusion: The ideal of dying at home is nuanced by identity, relational, and structural contexts. Knowledge from this study can inform realistic and practical person-centered planning across care settings. It can also help create more representative public policy and health system quality indicators regarding a 'good death' that do not rely on or perpetuate undeveloped and unrealistic assumptions about dying, home, and family care.

Changes in Place of Death of Older Adults during the COVID-19 Pandemic: A Retrospective Study from an Aging Country.

In the COVID-19 pandemic, due to the difficulties in patients' applications to health centres, changes have occurred in the places of death of older adults. It is aimed to investigate the change in the places of death of older adults in Turkey, which is one of the countries most affected by the pandemic. Patients admitted to the geriatric outpatient clinic of a university hospital from 01.01.2013 to 29.02.2020 were included. Place and date of death were recorded as hospital or out-of-hospital death. According to results, while the median age of those who died during the pandemic was higher than before (p < 0.001) and during the pandemic, the hospital mortality ratio was higher than before. During the pandemic period, the hospital mortality ratio of older adults has increased in Turkey. This situation, which has occurred despite the increasing healthcare burden, can show the importance of the measures taken and robust health infrastructure.

How people with intellectual disability are dying and implications for quality care

The characteristics of quality end-of-life care for people with intellectual disability are becoming increasingly clear. The research also shows the urgent and growing need for care, for an ageing population with increased incidence of life-limiting illnesses requiring often extended periods of care. A necessary first step to providing quality end-of-life care is to understand the conditions under which this group currently experiences death. This chapters uses the international literature to offer a picture about the current patterns of death, including death causes, age at and place of death, anticipated and potentially avoidable deaths, and deaths during the COVID-19 pandemic. Throughout, comparisons are made to the general population. Reflection questions to translate research to practice are given, as well as practical resources. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Dying with Cancer and COVID-19, with Special Reference to Lung Cancer: Frailty as a Risk Factor.

Older age and frailty have been associated with COVID-19 deaths, but frailty has seldom been studied in the context of cancer. The aim of this paper was therefore to study frailty (measured using the Hospital Frailty Risk Score) and other risk factors in patients who died with advanced cancer and a concomitant COVID-19 infection, with special reference to lung cancer. Of 4312 patients who died with cancer, 282 had concomitant COVID-19 (within the last 30 days), and these patients were significantly older, more often men, and residents of nursing homes. They often had less access to specialized palliative care, and they died more often in acute hospital settings. Patients with cancer who died with COVID-19 were more often frail (57% vs. 45%, p = 0.0002), and frailty was independently associated with COVID-19-related deaths, both in univariable and multivariable regression models, as well as when controlling for age, sex, socioeconomic factors on an area level, and comorbidity (measured using the Charlson Comorbidity Index). In the final multivariable model, where patients with cancer who died in nursing homes were excluded, belonging to the high-risk frailty group (OR 2.07 (1.31-3.27), p = 0.002) was the strongest prognostic variable in the model. In a separate analysis of a subgroup of deaths due to lung cancer (n = 653, of which 45 deaths occurred with concomitant COVID-19), the above associations were not significant, possibly due to too-few cases. In conclusion, frailty is a strong predictor of cancer deaths and should be addressed in cancer care.

THE CREATION OF HOSPICE OUTREACH DISCHARGE SUPPORT (HODS) TEAM

Background Nottinghamshire Hospice's day therapy unit closed its doors to patients during the COVID-19 pandemic. Government advice was supporting discharge from hospital wherever possible (NHS England and NHS Improvement, 2020). When asked, more than four in five people say they would prefer to die at home (Hoare, Morris, Kelly, et al., 2015). Patients receiving care from specialist palliative care teams tend to do better than those without (Higginson & Evans, 2010). Aims To expedite the discharge of patients at end-of-life from hospital and prevent unnecessary hospital admission for those in the community so that more people achieve their preferred place of death (PPD) with the provision of a dedicated palliative care service. Methods March-May 2020: consultations with fast track continuing care (FTCC), model planning, internal consultation, workforce transformation. May-July 2020: recruitment, service launch. July-March 2021: continuous service provision. We worked closely alongside FTCC to support patients either in hospital that wished to come home but needed a package of care or, patients that were deteriorating at home and required end-of-life care. An initial assessment by a registered nurse from the Hospice Outreach Discharge Support (HODS) team meant more timely referral into extended palliative community services including provision of specialist equipment and access to other hospice services e.g. bereavement support. It also focuses on the completion of EPaCCS and ReSPECT forms identifying PPD. Results Number of patients treated by HODS May 20 - March 21 = 195. 64% (124) died at home. 23% (44) remained well enough to be discharged to domiciliary care agency. 10% (20) admitted to hospital. 3% (6) admitted to nursing home. Average length of stay on HODS = 10 days PPD achieved = 95.87% [4] Conclusion The creation of HODS allows more people at end-of-life to remain in their PPD and with greater access to support services preventing carer burnout and unnecessary admission to hospital.

Excess deaths from non-COVID-19-related causes in Japan and 47 prefectures from January 2020 through May 2021 by place of death.

Excess deaths, including all-causes mortality, were confirmed for the first time in Japan in April 2021. However, little is known about the indirect effects of COVID-19 on the number of non-COVID-19-related deaths. We then estimated the excess deaths from non-COVID-19-related causes in Japan and its 47 prefectures from January 2020 through May 2021 by place of death. Vital statistical data on deaths were obtained from the Ministry of Health, Labour and Welfare. Using quasi-Poisson regression models, we estimated the expected weekly number of deaths due to all-causes excluding COVID-19 (non-COVID-19) and due to respiratory disease, circulatory disease, malignant neoplasms, and senility. Estimates were made separately for deaths in all locations, as well as for deaths in hospitals and clinics, in nursing homes and elderly care facilities, and at home. We defined a week with excess deaths as one in which the observed number of deaths exceeded the upper bound of the two-sided 95% prediction interval. Excess death was expressed as a range of differences between the observed and expected number of deaths and the 95% upper bound of the two-sided predictive interval. The excess percentage was calculated as the number of excess deaths divided by the expected number of deaths. At the national level, excess deaths from non-COVID-19-related all-causes were observed during April 19 to May 16, 2021. The largest excess percentage was 2.73-8.58% (excess deaths 689-2161) in the week of May 3-9. Similar trends were observed for all four cause categories. The cause-of-death categories which contributed to the excesses showed heterogeneity among prefectures. When stratified by place of death, excess mortality tended to be observed in nursing homes and elderly care facilities for all categories, in hospitals and clinics for circulatory disease, and at home for respiratory disease, malignant neoplasms, and senility. A caution is necessary that for the lastest three months (March-May 2021), adjusted data were used to account for possible reporting delays.

Changes in cancer-related mortality during the COVID-19 pandemic in the United States

Background: The coronavirus disease 2019 (COVID-19) pandemic resulted in delayed medical care that may have led to increased death rates in 2020 among people with medical conditions such as cancer. This study examined changes in cancer-related mortality between 2019 and 2020. Methods: We used the US 2019-2020 Multiple Cause of Death database from the CDC WONDER to identify cancer-related deaths, defined as decedents with invasive or noninvasive cancer as a contributing cause of death (ICD-10 codes: C00-C97 and D00-D09). We compared age-standardized cancer-related annual and monthly mortality rates (per 100,000 person-years and person-months, respectively) in January-December 2020 (pandemic) versus January-December 2019 (pre-pandemic) overall and stratified by rurality and place of death. We calculated the 2020 excess death by comparing the numbers of observed death with the projected death based on age-specific cancer-related death rate from 2015 to 2019. Results: The number of cancer-related deaths was 686 054 in 2020, up from 664 888 in 2019, with an annual increase of 3.2%. Compared to the number of projected deaths for 2020 (666 286), the number of cancer-related excess deaths was 19 768 in 2020. Annual age-standardized cancer-related mortality rate (per 100,000 person-years) continuously decreased from 173.7 in 2015 to 162.1 in 2019, while it increased to 164.1 in 2020 (2020 vs 2019 rate ratio (RR): 1.013, 95% confidence interval (CI): 1.009 - 1.016). The cancer-related monthly mortality rate was higher in April 2020 (RR: 1.032, 95% CI: 1.020 - 1.044) when healthcare capacity was most challenged by the pandemic, subsequently declined in May and June 2020, and higher mortality rates were again observed each month from July to December 2020 compared to 2019. In large metropolitan areas, the largest increase in cancer-related mortality was observed in April 2020, while in non-metropolitan areas, the largest increases occurred from July to December 2020, coinciding with the time-spatial pattern of COVID-19 incidence in the country. Compared to 2019, cancer-related mortality rates were lower from March to December 2020 in medical facilities, hospice facilities, and nursing homes or long-term care settings but higher in decedent's homes. Conclusions: The COVID-19 pandemic led to significant increases in cancer-related deaths in 2020 versus 2019. Ongoing evaluation of the spatialtemporal effects of the pandemic on cancer care and outcomes is warranted, especially in relation to patterns in vaccine uptake and COVID-19 hospitalization rates.

THE IMPACT OF ADVANCE CARE PLANNING ON PLACE OF DEATH DURING THE COVID-19 PANDEMIC: AN ANALYSIS OF DATA FROM COORDINATE MY CARE, A LARGE ELECTRONIC PALLIATIVE CARE COORDINATION SYSTEM

Background Anticipated severe illness at the start of the COVID-19 pandemic bought increased endorsement, awareness and provision of advance care planning in adults with serious illness. Place of death is often considered a surrogate quality indicator for end-of-life care. Aim To examine the impact of advance care planning on place of death for patients who died during the COVID-19 pandemic with a Coordinate My Care (CMC) record, the Electronic Palliative Care Coordination System currently commissioned in London. Methods Retrospective non-interventional cohort analysis of CMC records for patients aged over 18 who died between 20/03/20 and 05/03/21 with recorded place of death. Patient demographics, socio-economic position and advance care planning related factors associated with achieving preferred place of death were explored using logistic regression. Results 11,913 records were included. 76.9% patients died in their preference place of death (57.7% Home, 31.4% Care Home, 7.5% Hospice, 3.3% Hospital, 0.1% Other). A higher likelihood of dying in the preferred place was associated with a 'Not for resuscitation' (DNACPR) status (OR=1.55, 95% CI 1.23 to 1.95), a Ceiling of Treatment for 'Symptomatic Treatment' (when compared to 'Full active treatment', OR=3.55, 95% CI 2.78 to 4.53), discussions with family regarding resuscitation recommendations (OR=1.53, 95% CI 1.34 to 1.74) and at least 2 non-urgent care record views in the 30days before death (OR=1.27, 95% CI 1.23 to 1.43). Patients from areas of lower socio-economic position had a decreased likelihood of dying in their preferred place (OR= 0.65, 95% CI 0.54 to 0.79). Conclusion Components of Advance care planning carry potential to significantly influence place of death, even in times of crisis and when controlling for socio-economic and demographic determinants. Effective advance care planning is fundamental to achieving patient-centred, high-quality end-oflife care and factors relating to it must be considered in ongoing research on end-of-life outcomes.

USING FRAILTY REVIEWS TO MANAGE THE COVID-19 PANDEMIC IN AN EVIDENCE-BASED AND PERSONCENTRED MANNER ACROSS BUCKINGHAMSHIRE CARE HOMES

Aim NICE COVID-19 guidelines NG191 recognise that frailer patients, including those with a higher Rockwood Clinical Frailty Scale1 (CFS), are seldom improved by hospital admission. The project used a collaborative approach to undertake frailty reviews, aiming to reduce inappropriate hospital admissions. The reviews included discussing residents' preferred place of care and options in the event of deterioration, a Treatment Escalation Plan (TEP). Method A collaborative was formed between care home managers, pharmacists and geriatricians to review frailty factors in residents over 65 years, excluding those with Learning Disabilities. Care homes with high risk of COVID-19 were prioritised. A Standard Operational Procedure was approved within one month. Using existing resources only, the project was delivered over 3 months. Communication was sent to GP practices, care homes and residents/families and consent was obtained. Templates were developed and education delivered. Results Review outcomes were recorded electronically onto the GP clinical system. Care homes kept a copy and informed residents/ families of the outcome. 595 residents were reviewed in 21 care homes. Preliminary analysis for 71 residents reviewed May 2020 to April 2021 show: • 42 survivors, 33 with severe frailty (CFS 7-9), 9 not severely frail (CFS<7). Out of total 28 residents with TEP indicating avoidance of hospital admission, 23 were not admitted and 5 had single hospital admission. 14 residents TEP included hospital management of whom 7 were admitted. • 26 of the 29 deceased residents were severely frail. 96% died in their preferred place of death. Conclusion Clinical leadership demonstrated courage and capacity to challenge the status quo, improve organisational processes and innovate practice. This helped staff morale at a difficult time of immense pressure and positively enhanced care homes' profile and residents' experience.

Social characterization of COVID-19 in the state of Amazonas, Brazil

Objectives: To compare the number of deaths that occurred in the state of Amazonas and in Brazil, from March 16th to August 20th 2020, using the variables skin color, sex, place of death, age group and association with COVID-19, and secondly, to verify whether between 2019 and 2020, in the period from March 16th to August 20th, there was a significant change in the number of deaths from diseases not associated with COVID-19. Methods: We searched the databases of the Brazilian public agency "Transparency Portal" for the data on deaths that occurred in the state of Amazonas and Brazil in the period from March 16th to August 20th, 2019 and 2020. The absolute frequencies and percentages of the variables studied were used for statistical analysis. Results: COVID-19 was responsible for an 11.01% increase in deaths in Brazil;however, this rate quadrupled in the state of Amazonas. In relation to age group, there was a similar percentage between Amazonas and the national average. The stratified analysis showed significant differences between genders and races, with higher death rates in men and people of brown/black skin. The number of deaths at home increased significantly, especially those from causes not associated with COVID-19. Conclusions: The national drop in deaths from diseases not associated with COVID between March and August 2020 in Brazil is misleading and may be due to the result of misreported causes of death.

Home Becomes the Most Common Place of Death for Cancer Patients During the COVID-19 Pandemic, A Descriptive Analysis in England

Background/aims: Despite increased numbers of deaths in England from COVID-19 and its co-lateral effect on acute services (569,700 in 2020 vs. 496,370 in 2019) the number of deaths from cancer was virtually unchanged (138,026 in 2020 vs. 137,851 in 2019). Deaths (all causes) at home have exceed the expected number every week since April 2020, (155,815 (27.4% of all deaths) in 2020 vs. 120,467 deaths (24.3%) in 2019. Cancer deaths accounted for 35.5% of all deaths at home in 2019. Aims: to investigate the contribution made by cancer patients to the increased deaths at home during the COVID-19 Pandemic in England. Methods: National Mortality data used to identify cancer deaths (underlying cause) and place of death in England in 2019 and 2020 and compared for place of death as a proportion of all cancer deaths. Results: Cancer increased as a % of all deaths in patients' own home in 2020 36.5% to 35.5%. The % of cancer deaths in hospital reduced significantly from 35% to 29% and increased in patient's home from 31% to 41%. Reductions in % cancer deaths occurred in Care Homes 15% to 13%), Hospice 8% to 15% but an increase in other places (relatives homes) 1.7% to 2.4%. Thus a 19% reduction in cancer deaths in hospital, 15% reduction in hospices but 33% increase in homes. Conclusions: In England, national strategy, improving choice of place to die achieved an 8-year 2011-19 small increase in cancer patients dying at home (28.9 to 31.1%). The COVID-19 pandemic caused a massive shift in the proportion of cancer patients (11%) and actual numbers (∼15,000) dying in their own or relatives private homes. It is not clear how much of this change was forced decisions (hospitals full of COVID-19, Hospice beds reduced) or personal choice influenced by severe visiting restrictions in hospital, care homes and hospices. The quality of care provided is also not known. If choice played a significant role, and the current increase is sustained, community palliative care needs to be increased to support more cancer patients to die at home.

Palliative Care Should be Part of a Public Health Pandemic Response - How Routine Data Analysis in the COVID-19 Pandemic in England Could Inform Level of Need and Deployment of Services

Background/aims: Palliative and End of Life Care (P&EOLC) services normally have a relatively fast turnover of patients, however, the monthly numbers in any setting/geography is usually predictable. In the COVID- 19 pandemic there was a seismic rise in the number dying (in England, 494,611 (2019), 568,070 (2020) and 321,474 (2021 January to July). Deaths peaked in the 1st and 2nd waves. Aims: To describe the temporal changes in demand for PEoLC services during the pandemic and geographical variation in impact on provision in different settings. Methods: Mortality data for England, January 2019 to July 2021was analysed by calendar month, place of death, and geographically for 106 clinical commissioning groups (CCGs) = health administrations. Comparisons were made for 2020 and 2021 with reference to 2019. For 2021 the data January to July was compared to these months in 2019. The variations across CCGs were described using interquartile range (IQR). Results: In 2020 deaths increased by 15% (73,459) vs. 2019 and 10% (29,652) more in 2021(Jan to July) c.f. 2019. 2020 saw increases in deaths of: 29% (35,342) at home, 21% (23,281) in care homes, 7% (15,970) in hospital but -12% (3,470) in hospice. April 2020 (peak of first wave) showed the greatest change by month: of: 194% (17,732) care home, 86% (8,428) home, 84% (15,629) hospital, but -6% (150) in hospice. Across 106 CCGs in 2020 variation in increase in deaths had IQR: care home (14% to 29%), home (23% to 34%), hospital (2% to 13%), hospice (-23% to -4%), In April 2020 across 106 CCGs the variation in deaths had an IQR: care home (137% to 275%), home (58% to 105%), hospital (46% to 96%), hospice (-27% to 17%). Conclusions: These results emphasise the importance of joint working in a pandemic between the public health response and P&EOLC services to use data to mobilise expert P&EOLC support to organisations and geographies with greatest need. Rapid P&EOLC redeployment is key and new ways of working (phone/video) to support/train non-specialists to support the dying.

Patterns of Deaths in People With Dementia and Alzheimer's During the COVID-19 Pandemic in England: Lessons for Palliative Care Before the Next Pandemic

Background/aims: Older people had the highest death rates in England during the COVID-19 pandemic, before the vaccination programme. Deaths in care homes were especially high in the 1st Wave (W1) - April 2020 of the pandemic, with a lower peak in the 2nd Wave (W2) - December 2020/January 2021. People with Dementia and Alzheimer's (D&A)) were among the most vulnerable to become victims to COVID-19. Aims: To describe mortality patterns in people with (D&A) during the COVID-19 pandemic to learn lessons for Palliative and End of Life Care (P&EOLC) for D&A in pandemics. Methods: Mortality data in England, January 2019 to May 2021 analysed by calendar month and place of death for D&A as underlying cause (UC) and contributory cause (CC) on death registrations. The key underlying causes for D&A CC deaths were identified. Comparisons were made for 2020 with 2019 and for W1 and W2 the same months in 2019/20 using descriptive statistics. Results: In 2019, 64,468 people died with D&A as UC vs. 67,872 in 2020 (+5.3%), but strikingly deaths with D&A as CC increased 69% (26,445 to 44,624). The W1 and W2 peaks for D&A deaths were highly significant but different in nature. In W1 79% (8,435) D&A UC deaths were in care homes vs. 64% (3,435) 2019. For D&A CC deaths in W1 (April 2020) there was ∼400% increase in deaths (2,146 to 10,682) and 325% and 569% increases in hospital and care home deaths. In W1 COVID-19 (7,496 deaths) was the main (70%) UC for people dying with D&A as CC, increases also for Circulatory Disease +44%, Cancer +31%, Parkinsons +117% and respiratory disease (COPD) + 69.3%. W2 saw a 19% reduction in D&A UC deaths but +139% as CC with COVID-19 main UC. Conclusions: People with D&A were extremely vulnerable to risk of death during the COVID-19 pandemic, especially if living in a care-home and due to pressures on healthcare. The speed of surge in deaths and impact on care homes highlights the critical need for Advance Care Plans/Power of Attorney for people with D&A and especially training of care home staff in P&EOLC.

Palliative Care in the UK During the COVID-19 Pandemic: Provision, Policy and Practice

The UK has a global reputation for provision of high-quality palliative care. Yet hundreds of thousands of people die each year in the UK needing palliative care but not receiving it. And there are persistent - and increasing - inequalities in access to palliative care including by age, diagnosis, deprivation and ethnicity. Projections studies have shown large increases in the future palliative care needs which will be driven by ageing and dementia, populations that can be least likely to access palliative care. The COVID-19 pandemic provided a stress-test for palliative care. Over 150,000 people have died from COVID-19 in the UK to date. The place of death in the UK has shifted into the community, with a 41% increase in home deaths during 2020. Care home deaths increased three-folk during the first pandemic wave. However, data from primary care and care homes indicates poor integration of palliative and end of life care across care settings;and the experiences, care needs and outcomes of people dying in community settings during the pandemic have had little scrutiny. This presentation will draw on data from three research studies: the CovPall and CovPall-CareHomes studies, and the Marie Curie Better End of Life programme. Data from these three studies will be used to consider (i) what we learnt about provision of palliative and end of life care during the COVID-19 pandemic, and (ii) how this data has informed priorities for strengthening palliative care beyond the pandemic.