Scrutiny of schizophrenia end-of-life care needed
medwireNews: A population-based study shows that patients with schizophrenia are more likely to die in a nursing home than mentally healthy individuals, raising questions about the adequacy of palliative care they receive in this setting.
"Place of death is an important issue in end-of-life care," note authors Patricia Martens (Manitoba Centre for Health Policy, Winnipeg, Canada) and colleagues.
"Our present findings… underscore the importance of examining the staff mix in nursing homes and the necessity of psychiatric specialist training for nursing home health care providers," they add.
The researchers used administrative databases at their centre to compare the causes and places of death for 3943 schizophrenia patients and 11,827 individuals without schizophrenia who were matched for age, gender, geography and date of death. All of the patients died between April 1995 and March 2008.
The median age of death for the patients with schizophrenia was 77 years old, which, the authors say, refutes suggestion in the medical literature of an elevated risk for early death among patients with schizophrenia and underscores the importance of appropriate end-of-life care.
For schizophrenia patients aged 60 years or older, the three most common causes of death were circulatory system disease (35.8 vs 36.8% of deaths in counterparts without schizophrenia), cancer (15.2 vs 27.2%), and respiratory system disease (12.7 vs 8.6%).
Given that there is a two to three times higher elevated overall mortality rate for schizophrenia patients compared with the rest of the population, says the team, referring to a recent European small community-based cohort research study, these rates translate into a potentially elevated risk for death from both circulatory and respiratory disease and a similar rate of cancer deaths.
Irrespective of the cause of death, patients with schizophrenia were twice as likely to die in a nursing home as their mentally healthy counterparts (29.7 vs 13.9%), and less likely to die in hospital (55.5 vs 70.5%).
For cancer deaths specifically, the proportion of schizophrenia patients who died in a nursing home was more than four times higher than that for the control individuals. This pattern persisted for both circulatory and respiratory deaths.
The researchers stress in the Journal of Clinical Psychiatry that "there is no doubt that attending to the challenges of end-stage chronic illness, such as cancer, respiratory, and circulatory disease, requires exquisite skill and expertise and that those skills are more likely to be found within tertiary care settings or hospital-based palliative care rather than nursing homes."
They add: "For patients with schizophrenia, disease-driven palliation needs and where they die needs to be examined."
This seems particularly true given that patients with schizophrenia dying in nursing homes were no more likely to see general practitioners, specialists, or to be hospitalized than their mentally healthy peers.
"This finding raises the uncomfortable question of how the additional mental and physical healthcare needs of these patients were addressed within this particular setting," Martens et al highlight.
"It appears that dying with schizophrenia in a nursing home does not garner additional investment of health care resources."
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By Lucy Piper, Senior medwireNews Reporter