PDF(Pubmed)
Abstract：
Background: Research on deaths during COVID-19 has largely focused on hospitals and nursing homes. Less is known about medically complex patients receiving care in the community. We examined care disruptions and end-of-life experiences of homebound patients receiving home-based primary care (HBPC) in New York City during the initial 2020 COVID-19 surge. Methods: We conducted a retrospective chart review of patients enrolled in Mount Sinai Visiting Doctors who died between March 1-June 30, 2020. We collected patient sociodemographic and clinical data and analyzed care disruptions and end-of-life experiences using clinical notes, informed by thematic and narrative analysis. Results: Among 1300 homebound patients, 112 (9%) died during the study period. Patients who died were more likely to be older, non-Hispanic white, and have dementia than those who survived. Thirty percent of decedents had confirmed or probable COVID-19. Fifty-eight (52%) were referred to hospice and 50 enrolled. Seventy-three percent died at home. We identified multiple intersecting disruptions in family caregiving, paid caregiving, medical supplies and services, and hospice care, as well as hospital avoidance, complicating EOL experiences. The HBPC team responded by providing clinical, logistical and emotional support to patients and families. Conclusion: Despite substantial care disruptions, the majority of patients in our study died at home with support from their HBPC team as the practice worked to manage care disruptions. Our findings suggest HBPC\'s multi-disciplinary, team-based model may be uniquely suited to meet the needs of the most medically and socially vulnerable older adults at end of life during public health emergencies.
摘要：
背景：对COVID-19期间死亡的研究主要集中在医院和疗养院。关于在社区接受护理的医学复杂患者的了解较少。我们调查了纽约市在2020年COVID-19初期激增期间接受家庭初级保健（HBPC）的居家患者的护理中断和临终经历。方法：我们对在2020年3月1日至6月30日期间死亡的西奈山门诊医生的患者进行了回顾性图表回顾。我们收集了患者的社会人口统计学和临床数据，并使用临床笔记分析了护理中断和临终经历，由主题和叙事分析提供信息。结果：在1300名患者中，112人（9%）在研究期间死亡。死亡的病人年龄更大，非西班牙裔白人,比那些幸存下来的人还得了痴呆症。30%的死者确认或可能患有COVID-19。58人(52%)转诊到临终关怀医院，50人登记。73％的人在家中死亡。我们发现了家庭护理中的多个交叉中断，有偿护理，医疗用品和服务，和临终关怀,以及医院的回避，复杂的EOL体验。HBPC团队的回应是提供临床，为患者和家属提供后勤和情感支持。结论：尽管有大量的护理中断，在我们的研究中,大多数患者在他们的HBPC团队的支持下在家中死亡,因为该实践致力于管理护理中断.我们的发现表明HBPC的多学科，基于团队的模式可能特别适合于在突发公共卫生事件期间满足医学和社会上最脆弱的老年人在生命结束时的需求.
