Practice Patterns and Perceptions About Parenteral Hydration in the ...

Vol. 43 No. 1 January 2012

Journal of Pain and Symptom Management

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Original Article

Practice Patterns and Perceptions About Parenteral Hydration in the Last Weeks of Life: A Survey of Palliative Care Physicians in Latin America Isabel Torres-Vigil, DrPH, Tito R. Mendoza, PhD, Alberto Alonso-Babarro, MD, Liliana De Lima, MHA, Marylou Cardenas-Turanzas, MD, DrPH, Mike Hernandez, MS, Allison de la Rosa, MPH, and Eduardo Bruera, MD Graduate College of Social Work (I.T.-V.), University of Houston; and Dorothy I. Height Center for Health Equity & Evaluation Research (I.T.-V., A.d.l.R.), Division of Cancer Prevention & Population Sciences, Department of Health Disparities Research; Department of Palliative Care and Rehabilitation Medicine (I.T.-V., E.B.); Department of Symptom Research (T.R.M.), Division of Internal Medicine; Department of Critical Care Medicine (M.C.-T.); and Department of Biostatistics (M.H.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; Palliative Care Unit (A.A.-B.), Hospital Universitario La Paz, Madrid, Spain; Latin American Association for Palliative Care (L.D.L.), Buenos Aires, Argentina; and The International Association for Hospice and Palliative Care (L.D.L.), Houston, Texas, USA

Abstract Context. Parenteral hydration at the end of life is controversial and has generated considerable debate for decades. Objectives. To identify palliative care physician parenteral hydration prescribing patterns and factors that influence prescribing levels (PLs) for patients during their last weeks of life. Methods. A cross-sectional, representative online survey of Latin American palliative care physicians was conducted in 2010. Physicians were asked to report the percentage of their terminally ill patients for whom they prescribed parenteral hydration. Predictors of parenteral hydration PLs were identified using logistic regression analysis. Results. Two hundred thirty-eight of 320 physicians completed the survey (74% response rate). Sixty percent of physicians reported prescribing parenteral hydration to 40%e100% of their patients during the last weeks of life. Factors influencing moderate/high PLs were the following: agreeing that parenteral hydration is clinically and psychologically efficacious (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.5e8.3), disagreeing that withholding parenteral hydration alleviates symptoms (OR 3.3, 95% CI 1.3e8.1), agreeing that parenteral hydration is essential for meeting the minimum standards of care (OR 3.2, 95% CI

Address correspondence to: Isabel Torres-Vigil, DrPH, Graduate College of Social Work, University of Houston, 110HA Social Work Building #409, Ó 2012 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved.

Houston, TX 77204-4013, USA. E-mail: istorres@ uh.edu Accepted for publication: March 4, 2011. 0885-3924/$ - see front matter doi:10.1016/j.jpainsymman.2011.03.016

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1.4e7.5), preferring the subcutaneous route of parenteral hydration for patient comfort and home use (OR 2.9, 95% CI 1.3e6.5), and being younger than 45 years of age (OR 2.6, 95% CI 1.3e5.2). Conclusion. The strongest determinant of prescribing patterns was agreement with the clinical/psychological efficaciousness of parenteral hydration. Our results reflect parenteral hydration prescribing patterns and perceptions that substantially differ from the conventional/traditional hospice philosophy. These findings suggest that the decision to prescribe or withhold parenteral hydration is largely based on clinical perceptions and that most palliative care physicians from this region of the world individualize treatment decisions. J Pain Symptom Manage 2012;43:47e58. Ó 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Parenteral hydration, palliative care, Latin America, physician survey

Introduction Most patients decrease their oral intake before death. Parenteral hydration at the end of life (EOL), however, is very controversial, and health care professionals have debated the potential benefits and disadvantages of parenteral hydration for decades. Practice patterns related to parenteral hydration at the EOL also vary. In the U.S., for instance, whereas virtually 100% of advanced cancer patients receiving care in hospitals or acute care settings receive parenteral hydration, few of the advanced cancer patients in hospice care are hydrated parenterally. These divergent practice patterns in the U.S. result mainly from a reimbursement system that provides financial incentives to administer parenteral fluids and medications intravenously in the acute care setting but not in the hospice setting.1,2 Proponents of parenteral hydration at the EOL argue that hydration can reduce dehydration-induced delirium in terminally ill patients and correct body fluid electrolytes that may improve patient mental awareness and other symptoms. In contrast, others argue that parenteral hydration in dying patients may lead to fluid retention and increases in airway and gastrointestinal secretions.3,4 Despite recent findings suggesting that adequate hydration may facilitate symptom management,1,5 positions and practices regarding parenteral hydration may vary between hospital- and hospice-based physicians and also among palliative care experts.2,6e8

Patient and family decisions regarding parenteral hydration are significantly influenced by physician recommendations, which in turn may be informed by their attitudes and beliefs.9e11 Identifying the factors that influence palliative care physician prescribing patterns may provide important information for the proper management of dehydration in terminally ill patients. Yet, few surveys have assessed parenteral hydration prescribing patterns. To date, most surveys have been conducted with physicians from multiple specialties or combinations of physicians and other providers, such as nurses.6,12e14 These studies have predominantly investigated provider attitudes and beliefs regarding parenteral hydration. One study assessed behavioral intentions to order parenteral hydration by using vignettes6 and another identified patient demographic and clinical factors influencing physician decisions to forgo the combination of artificial nutrition and hydration.14 The few preliminary studies focused exclusively on palliative care specialists used small convenience samples and were largely descriptive.15,16 One study, conducted with consecutive cancer patients admitted to a palliative care unit in Japan, identified the determinants of physician recommendations regarding parenteral hydration.10 To our knowledge, there have been no studies measuring prescribing behaviors conducted in large representative samples of physicians specializing in palliative care. Palliative care physicians are exposed daily to dehydration in patients at the EOL and assessing their parenteral hydration prescribing

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Parenteral Hydration in the Last Weeks of Life

patterns is key to understanding the management of dehydration at the EOL. Furthermore, the importance of this knowledge transcends the specialty of palliative medicine and is relevant to all physicians delivering care to dying patients. In Latin America, as in Canada and Europe, the administration of parenteral hydration and/or parenteral medications is not directly tied to acute hospitalizations and hospital reimbursements. Therefore, we hypothesized that the decision to order parenteral hydration in Latin America, both at home and in hospital, is strongly influenced by physicians’ clinical and logistical assessments and their attitudes and beliefs regarding parenteral hydration for patients during the last weeks of life. The purpose of this study was to identify Latin American palliative care physician prescribing patterns and perceptions (attitudes and beliefs) and the factors (physician demographic, training, and practice characteristics) influencing parenteral hydration prescribing levels (PLs) for patients during their last weeks of life.

Methods Study Design and Study Population The study used a cross-sectional survey design to assess palliative care physician attitudes, beliefs, and prescribing patterns related to parenteral hydration during the last weeks of life. We invited all physician members (universal sample) of the Latin American Association of Palliative Care (ALCP) to participate in the self-administered, confidential, online survey. Physicians were eligible to participate if they practiced in Latin America and dedicated at least 30% of their practice to palliative care. The study was approved by the Institutional Review Board of The University of Texas M. D. Anderson Cancer Center.

Questionnaire Design and Development We developed an ad hoc questionnaire (Appendix; available from the authors and at jpsmjournal.com). Items and scales included in the questionnaire were drawn or adapted from those used in a survey in Italy of advanced cancer patients and their relatives4 and surveys of physicians and nurses in

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Japan.6,13 The questionnaire included demographic questions, items assessing practicesetting characteristics, background specialty, and experience in palliative care; 19 items on attitudes and beliefs related to parenteral hydration at the EOL; and 11 items to capture parenteral hydration prescribing patterns of the physicians and potential barriers to providing home-based parenteral hydration. The insertion of the title ‘‘Use of Parenteral Hydration in the Last Weeks of Life’’ before each section of the online questionnaire reminded respondents that questions were specific to the last weeks of life. The questionnaire was translated from English into Spanish (and back translated) and then pilot tested with six Latin American and Spanish palliative care physicians. A pretest was subsequently conducted with 10 palliative care physicians rehearsing the entire process from beginning to end. The final questionnaire took between 10 and 15 minutes to complete online.

Data Collection We used data collection methods similar to other online surveys of physicians.17,18 The survey was posted online and hosted on a secure web server using an online survey hosting tool. Data were collected from February 2010 through April 2010. Invitation letters/e-mails signed by the president of the ALCP and the study investigators were e-mailed to 360 physicians. Potential respondents were requested to confirm receipt of the invitation. Once confirmed, respondents received a second e-mail containing the link to the web page and an individual control number to enter the survey. A reminder e-mail was sent to nonresponders up to four times. Physicians reporting that they practiced palliative care at least 30% of their time and practiced in Latin America were eligible to complete the survey. The 30% criterion established by Bruera et al. has been used in other surveys to identify and survey palliative care physicians.19,20 Receipt of the completed survey was considered informed consent. Monetary incentives were not provided, and personal identifiers were not included in the survey.

Measurements Dependent Variable. We assessed the setting (hospital and home), the types (intravenous

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[IV], subcutaneous [SC], and rectal), and the proportion of patients prescribed parenteral hydration in the last weeks of life. The dependent variable was assessed by asking, ‘‘In what percentage of your terminally ill patients overall do you prescribe parenteral hydration?’’ This item, a scale ranging from 0% to 100%, was dichotomized into low prescribers (0% e30%) and moderate-to-high prescribers (40%e100%). Independent Variables. Independent variables included sociodemographic characteristics (i.e., age, gender, and religious affiliation), practice characteristics (i.e., type of practice and proportion of practice dedicated to oncology), training and experience (i.e., background specialty and years of palliative care experience), and attitudes and beliefs regarding parenteral hydration in the last weeks of life. Attitudes and beliefs were assessed by a 19-item, five-point Likert-like scale ranging from ‘‘totally agree’’ to ‘‘totally disagree.’’ Each item was dichotomized into ‘‘strongly agree to agree’’ vs. ‘‘neutral, disagree and strongly disagree.’’ Finally, respondents were asked to select the top three barriers to homebased parenteral hydration from a list of six.

Statistical Analyses Study variables were summarized using standard descriptive statistics. The distributional characteristics of relevant variables were examined using box plots and histograms to ensure normality assumptions. Estimates of the proportion of physicians prescribing parenteral hydration were obtained, along with 95% confidence intervals (CIs). Bivariate analyses using the Chi-squared test were conducted to examine the associations between parenteral hydration PLs and respondent characteristics (i.e., physician demographic, training, and practice characteristics and their attitudes and beliefs toward parenteral hydration). An exploratory factor analysis using principal axis factoring with oblique rotation was conducted to examine the factor structure of the 19-item measure of attitudes and beliefs. Several factor analytic models were tested and refined using the criteria of simple structure, model fit, and interpretability. The 19-item measure was reduced to 13 items representing three factors that met

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the above criteria. Factors with at least an internal consistency reliability coefficient of 0.70 were included in the multivariate model for analysis.21 Independent variables were included in the model if P < 0.15 in the bivariate analyses. We assessed collinearity among the covariates and the goodness of fit with the Hosmer and Lemeshow test. All analyses were performed using SPSS, version 17.0, software for Windows (SPSS, Inc., Chicago, IL).

Results A total of 238 palliative care physicians from 18 Latin American countries completed the survey. Three hundred and sixty physicians were sent an invitation to complete the survey. Of these, eight were undeliverable and 32 were ineligible, resulting in a total of 320 eligible physicians. Of these, 243 began the survey and 238 completed it, yielding a response rate of 74% (238/320). Table 1 details the characteristics of the study participants and displays the bivariate association between PLs and physician characteristics. Most respondents were from Argentina (25%), followed by Brazil (17%) and Mexico (11%). A subgroup analysis of these three countries yielded no differences across countries regarding PLs (P ¼ 0.711). Almost the entire sample was urban, with 84% practicing in a national or provincial/state capital city. The majority (92%) reported that they had prescribed or administered parenteral hydration (SC or IV) to their patients in their last weeks of life within the last year and 60% prescribed parenteral hydration to 40%e100% of their patients. Physicians prescribing parenteral hydration to a larger proportion of their patients tended to be younger than 45 years of age, dedicated a larger proportion of their practice to oncology patients, and practiced in a hospice, a free-standing or hospital-based palliative care unit, or a mobile consultation team. Twenty-three percent of physicians reported the existence of an institutional practice guideline regarding parenteral hydration in the last weeks of life. On average, physicians prescribed parenteral hydration to 57% of hospitalized patients and 45% of at-home patients. The IV route was reportedly prescribed more

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Table 1 Sample Characteristics and Association Between Parenteral Hydration PLs During the Last Weeks of Life and Demographic, Training, and Practice Characteristics (n ¼ 238) Factors

n (%)

Moderate/High PL (40%e100% of Patients)

P-value

All respondents Sex Male Female

238 (100)

60

NA

95 (40) 143 (60)

60 61

0.929

Age