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Context: Home visits at the end of life decrease hospitalizations and hospital deaths, which reduces healthcare costs and aligns with most patients' wishes. In addition to family physicians, nurse practitioners (NPs) play a critical role in meeting the rising demand for home and community-based palliative care. However, very few population-level studies have examined practice patterns of NPs delivering home-based end-of-life care and the collaboration between physicians and NPs. Objective: To describe the characteristics and outcomes of patients receiving home-based palliative care provided by physicians and NPs in the last 90 days of life. Study Design and Analysis: Retrospective population-based study with a descriptive analysis of patient characteristics and multivariate logistic regression analyses of end-of- life outcomes controlling for patients' demographics, health, and healthcare use. Setting or Dataset: Healthcare administrative data in Ontario, Canada. Population Studied: Adults 19 years and older who died between January 1, 2018, and December 31, 2019, and received home care in their last 90 days of life (N=103,664). Intervention/Instrument: Receipt of home visits by an NP, physician, or both. Outcome Measures: Receipt of medications for symptoms (e.g., pain, delirium/agitation, and terminal secretion) in the last 3 weeks of life, acute care use in the last 3 weeks of life, and location of death. Results: Over half (56.9%) of the decedents did not receive any visits from an NP or physician; 3.8% received at least 1 visit from an NP (and no physician visits), 34.5% received at least 1 visit from a physician (but no NP visits), and 4.9% received at least 1 visit from each. NP visits were more prevalent among patients living in rural areas. Patients who received at least 1 home visit were less likely to be hospitalized, more likely to have received medications for symptom management, and more likely to experience a community-based death. These associations were strongest when patients received home visits from both NPs and physicians. Results from multivariable regression are forthcoming. Conclusions: The receipt of at least 1 NP or physician home visit at the end of life can significantly reduce acute care use, improve access to symptom management medications, and mitigate hospital-based deaths. Collaboration between NPs and physicians was associated with greater benefits to patients' outcomes., Presenters Amy Ramzy, BHSc, Mary Scott, MSc, Sarina Isenberg, Colleen Webber, Carrie Heer, NP-PHC, MN, Maya Murmann, MSc, HBA, Jennifer Rayner, PhD, Roshanak Mahdavi, Peter Tanuseputro, David Ponka, MD, CCFP, [...]

The article focuses on responding to concerns raised by Gallagher et al. about "Medical Assistance in Dying, Palliative Care, Safety, and Structural Vulnerability," defending the scholarship and clarifying points related to data representation and interpretation. Topics include addressing factual errors in the response, clarifying the focus on patients receiving Medical Assistance in Dying (MAID) at the end of life.

As more jurisdictions consider legalizing medical assistance in dying or assisted death (AD), there is an ongoing debate about whether AD is driven by socioeconomic deprivation or inadequate supportive services. Attention has shifted away from population studies that refute this narrative, and focused on individual cases reported in the media that would appear to support these concerns. In this editorial, the authors address these concerns using recent experience in Canada, and argue that even if we accept these stories at face value, the logical policy response would be to address the root causes of structural vulnerability rather than attempt to restrict access to AD. In terms of concerns about safety, the authors go on to point out the parallels between media reports about the misuse of AD and reports of wrongful deaths due to the misuse of palliative care (PC) in jurisdictions where AD was not legal. Ultimately, we cannot justify having a different response to these reports when they apply to AD instead of PC, and nobody has argued that PC should be criminalized in response to such reports. If we are skeptical of the oversight mechanisms used for AD in Canada, we must be equally skeptical of the oversight mechanisms used for end-of-life care in every jurisdiction where AD is not legal, and ask whether prohibiting AD protects the lives of the vulnerable any better than legalization of AD with safeguards. [ABSTRACT FROM AUTHOR]

Medical Assistance in Dying (MAID) and palliative care often have an antagonistic relationship in jurisdictions where both are legal, but the early ethical and legal history of palliative care closely mirrors that of MAID in important ways. Palliative practices that are commonplace today were considered homicide or "medically assisted death" in most jurisdictions until quite recently. Moreover, while many patients request MAID today for reasons that are criticized as "ableist," the same rationale is accepted without comment or judgment when used to justify withdrawal of life support or a discontinuation of life-prolonging therapies. Concerns about factors that undermine autonomous decisions for MAID would apply equally to routine palliative care practices. By the same token, palliative care exists because no field in medicine is able to fix every problem it encounters. It is ironic, therefore, that some palliative care providers oppose MAID with the hubristic argument that we can relieve all forms of suffering. Palliative care providers may choose not to participate in MAID, but palliative care and MAID do not have to be mutually exclusive and are often complementary and synergistic for patients and families. [ABSTRACT FROM AUTHOR]

Background: Medical Assistance in Dying (MAiD) was legalized in Canada in June 2016. There are no documented experiences of MAiD provision within a home palliative care program. The majority of palliative care physicians in Canada object to MAiD. As one of the largest home-based palliative care providers in Canada, the Temmy Latner Centre for Palliative Care (TLCPC) developed processes to implement MAiD provision within a home palliative care team with diverse attitudes toward MAiD. Objective: To demonstrate the feasibility of providing MAiD within a home palliative care setting and describe the population that received MAiD in the first year of legalization. Design: A retrospective chart review identified patients who received or were assessed for MAiD and had a known outcome between June 17, 2016 and June 30, 2017. Setting/Subjects: Patients receiving home-based palliative care. Measurements: Data extracted included age, gender, primary diagnosis, length of time receiving home-based palliative care, and final clinical outcome. Results: Of the 45 patients who were assessed for MAiD, 27 (60%) received MAiD and 18 (40%) did not. The mean age was 74 (range 20–95), 24 (53%) were male, and 33 (73%) had cancer as a primary diagnosis. These 27 patients represent 1.2% of our total patient population during this time period. Conclusions: MAiD was accessed by 1.2% of the patients within a home palliative care center in the first year of legalization. Patient demographics were consistent with those documented elsewhere. The TLCPC process accommodates the diverse viewpoints of clinicians and emphasizes continuity of palliative care provision. [ABSTRACT FROM AUTHOR]