ASSOCIATIONS BETWEEN CARE PROVIDED IN THE HOME AND HOME DEATH
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Context: It is projected that the number of annual deaths in Canada will increase from 259,000 in 2011 to 425,000 by 2036. Most Canadians prefer to die at home. Currently, the proportion of individuals receiving formal and informal care is not known in Canada. Formal medical care at home has been associated with home deaths in other countries, but we know little about this association nor the association of formal home support and a home death in Canada. The objectives of this thesis were to examine (1) the proportion of individuals at the end of life receiving formal and informal care in their home in Nova Scotia, (2) the association between receiving formal care at home and having a home death, and (3) the association between the type of formal care at home (medical only or home support with or without medical care) and having a home death. Methods: Data came from the population-based mortality follow-back survey conducted in Nova Scotia between 2010-2012. Surrogate respondents, the next-of-kin listed on the death certificate, of Nova Scotians who died in this period answered a survey. This follow-back survey provides a snapshot of the experience of end of life care among adults in Nova Scotia with an emphasis on unmet needs, preferences, and satisfaction with the end of life care that the decedents received. This thesis included the decedents who spent at least one day at home during the last 30 days of life (n=694 for Objective 1 and n=662 for Objective 2) and the decedents who received formal care at home during the last 30 days of life (n=518 for Objective 3). The dependent variable (having a home death) was measured dichotomously. Care at home was measured as receiving formal care at home and receiving informal care at home. Formal care at home included medical care at home as well as home support with or without medical care at home. Through descriptive analysis, I identified the proportion of the decedents receiving care at home at the end of life. Using logistic regression, I examined whether receiving formal care at home is associated with having a home death, after adjustment for demographic, medical, and socioeconomic factors and informant characteristics. Using logistic regression, I examined which type of formal care (medical care at home or home support with or without medical care at home) had a stronger association with a home death, adjusting for the aforementioned variables. Findings: In 2010-2012, among those who spent at least one day at home in the last 30 days of life, 92.94% of decedents had care at home and 33.96% of the decedents had died at home. Decedents who received care at home had a higher proportion of individuals who received the majority of care at home. As for the type of care at home among those received care at home, 80.98% of decedents had informal care at home and 78.67% of decedents had formal care at home. Compared to those who did not receive formal care at home, those received formal care at home were 3.38 times more likely to die at home (95% Confidence Intervals [CI]: 1.96-5.85), after adjustment for the decedents’ demographic factors, medical factors, socioeconomic factors, and informant characteristics. Among those with good symptom management, after adjustment for the decedents’ demographic factors, medical factors, socioeconomic factors, and informant characteristics, receiving home support with or without medical care was 2.76 times (95% CI: 1.57-4.87) more likely to die at home compared to receiving medical care only. Conclusions: This study showed that receiving formal care at home was positively associated with a home death. Among those decedents with well-managed symptoms, receiving formal home support with or without medical care at home had a stronger positive association with a home death compared to receiving medical care only at home. This implies that individuals at the end of life need to firstly have their symptoms well managed to be able to die at home. With well-managed symptoms, formal home support had a positive association with a home death. This information will be useful for the development of a comprehensive provincial palliative care program by the Department of Health and Wellness in Nova Scotia.