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Population-based survey regarding factors contributing to expectation for death at home

Population-based survey regarding factors contributing to expectation for death at home Background: In 2015 in Japan 12.7% of people die at home. Since the government has no policy to increase the number of hospital beds, at-home deaths should inevitably increase in the near future. Previous researches regarding expected place of death have focused on end-of-life patients. The aim of this study is to clarify the percentage and factors of senior people who expect at-home deaths whether they are end-of-life or not. Methods: Using cross-sectional questionnaire survey data which had been taken by a research group with the sup- port from Tama City Medical Association ( Tokyo) in 2014, univariable and multivariable logistic regression analyses were conducted to identify associations among factors. The dependent variable was the expected site of death and other factors were set as independent variables. Results: Of 1781 respondents, 46.5% expected at-home deaths. Data from 1133 people were analyzed and 46.5% of those wanted at-home deaths. Factors significantly associated with expectation of at-home death were men, stand- alone houses for dwelling, expectation to continue life in Tama city, twosome life with the spouse, healthiness, and economic challenge. Conclusion: Percentage of those who expected at-home deaths was much higher than the latest percentage of at- home deaths. Some factors associated with expectation of at-home deaths in this study have never been discussed. Keywords: Terminal care, Surveys and questionnaires, Multivariable analyses or nursing homes for the elderly increased from 2.8% in Background 2005 to 8.6% in 2015, showing a considerable increase [1] As Japan becomes an aging society with declining birth (Fig. 1). In addition, according to the Working Group for rates and increasing mortality rates, the gap between the Analysis and Discussion of Medical and Nursing Care preferred and actual place of death is currently an impor- Information, in the Expert Panels on the Promotion of tant issue in medical care and welfare. It is estimated that Reforms with Medical and Nursing Care Information of the number of annual deaths in Japan will increase from the National Council on Social Security System Reform, 1.29 million in 2015 [1] to 1.67 million in 2040 [2]. In the hospital bed capacity in 2013 was 1.35 million, and the 1950s, homes accounted for 82.5% of places of death. In estimated hospital bed capacity by medical care function 2015, homes accounted for only 12.7% of places of death in 2025 is predicted to be 1.15–1.19 million [3]. There is while hospitals accounted for 78.4%. On the other hand, no plan to increase hospital bed capacity in the future. the idea of ending life in a familiar place has become It can be inferred that more people will die at home or common in the last decade. Home deaths increased in care facilities if there is no reduction in hospital stay, slightly from 12.2% in 2005 to 12.7% in 2015. The death among other aspects. Thus, it is important to explore fac rates for those who died at long-term care health facilities - tors that affect place of death in predicting the trend of medical and nursing care. *Correspondence: tsuchidatomoya@gmail.com A systematic review of factors influencing death at Division of General Practice, Department of Internal Medicine, Kawasaki home in terminally ill patients with cancer identified the Municipal Tama Hospital, 1-30-37 Shukugawara, Tama-ku, Kasawasaki-shi, Kanagawa-ken 214-8525, Japan following items as factors strongly associated with home Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 2 of 7 Fig. 1 Trends in deaths by place of death. Deaths at long-term care health facilities before 1989 and those at nursing homes for the elderly before 1995 are included in the category of home deaths. Excerpt from Trends in deaths by place of death. Annual Vital Statistics Report (Final) 2015, Ministry of Health, Labor and Welfare death: patients’ low functional status, patients’ prefer- 27.2, 52.4, and 10.9% in 2008, respectively, and the rates ences, use and intensity of home care, living arrange- for those who wanted to spend a certain period of time ments, and extended family support [4]. In addition, at home or die at home slightly increased. However, this meta-ethnography in Wahid et  al. lists the following survey showed that those who wanted to die at home items as barriers to home death: lack of knowledge, skills accounted for only 10% while many people preferred to of and support among informal carers and healthcare die in a medical institution. professionals, informal carer and family burden, recog- In a 2014 survey by the Review Committee on Aware- nizing death, inadequacy of processes such as advance ness Surveys of Palliative Care, etc., five types of patients care planning and discharge, and inherent patient diffi - answered to questions about preferred place of death. culties due to medical conditions or social circumstances. Those in a coma with progressive weakness for more than It also lists the following items as factors promoting half a year after a traffic accident and end-stage cancer home death: support for patients and healthcare profes- patients who had good appetite and judgement without sionals, skilled staff, coordination and effective commu - pain accounted for 10.3 and 71.7% of those who opted nication [5]. to spend their last years of life at home, respectively [7], Regarding the situation in Japan, the results of “the suggesting that this type of survey shows different results Surveys of Palliative Care” 1998 by “the Palliative Care depending on contexts. Meeting” showed that those who wanted to be hospital- The literature review by Takeu [8] identified the follow - ized in a medical institution or palliative care ward that ing items as factors commonly observed in home care they have visited as soon as possible accounted for 32.5%; patients who prefer home death: female, elderly, without those who wanted to receive home care and, if necessary, pain, without breathing difficulties, bedridden, and pref - be hospitalized in a medical institution or palliative care erence for home death. It identified the following items ward accounted for 48.7%; and those who preferred to die as factors commonly observed in families and caregivers: at homes accounted for 9.0% [6]. These rates changed to secondary caregivers included, non-spouse or child, and Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 3 of 7 preference for home death. It also identified the following Questionnaire items as factors commonly observed in medical care and The questionnaire included the following items: (1) age, home care services: “a visiting physician available, attend- sex, height, and weight; (2) residential district (one dis- ing physician’s or clinic’s positive attitude toward home trict is selected from 26 districts of Tama city); (3) resi- death, use of home care services, psychological support dence: detached houses, housing complexes of (1st or from the family.” Hattori et  al. stated that a decrease in 2nd or upper floor with/without elevator); (4) year of res - activities of daily living (ADL) 1  month before death is idence; (5) preference to continue to live; (6) family type; also a factor contributing to home death. They identi - (7) health conditions; (8) certified need for long-term fied the following items as barriers to home death: sense care; (9) instrumental ADL (IADL); (10) contribution to of burden felt by families, anxiety at the time of sudden community; (11) level of social activities; (12) affordabil - change, and anxiety about hospitalization at the time of ity; (13) families and relatives, the frequency of commu- sudden change [9]. Suzuki et al. listed the following items nication with friends; and (14) preferred place of death as factors enabling home death: the acceptance of the (Question is “Where do you want to die? Please circle home death by the family, patient preference for home one item “medical institution, home, family’s home, facil- death, presence or absence of family caregivers, introduc- ities for the elderly, facilities covered by long-term care tion of home care nursing, and relief of physical pain [10]. insurance, don’t know, others”). According to Sugikoto et al. in most cases, the major fac- tor contributing to the decision on the place of death was “patients’ preferences” [11]. Statistical analysis Tama City is located in the south-west suburb in Univariable and multivariable analyses were performed Tokyo. It is a unique city whose population has dramati- with preferred place of death as a dependent variable and cally increased within 30  years from less than 10,000 in other factors as independent variables. Regarding the 1960 to 140,000 in 1990 with the development of Tama dependent variables, preferred place of death was cat- New Town. Many residents are baby boomers who relo- egorized into a dichotomous variable: “home death” (i.e., cated into Tama in their thirties and forties in the late “home” or “family’s home”) and “non-home death” (i.e., 1970s and 1980s. However, the rate of aged 65 and above “medical institutions such as hospitals,” “elderly hous- in Tama City is expected to increase rapidly from 25.4% ing with supportive services,” or “facility such as special in 2015 to 32.6% in 2025 [12]. Thus, we thought it would elderly nursing home”). Responses of “do not know” and be possible to predict the near future of Japan by analyz- “other” are excluded from the analysis. ing the data on the preference for home death in Tama Changes were made to the independent variables city. before the analysis. Ages were categorized into three The purpose of this study was to examine the charac - groups based on age (i.e., 65–74, 75–84, and 85+ years). teristics of those who prefer to die at home by analyz- Residential areas were categorized into six nominal varia- ing data from a questionnaire survey [13] in residents of bles by the jurisdiction of six community general support Tama City aged 65 and above. centers. Residence year was converted into a dichoto- mous variable of ≥ 20 years or not. Family type was cate- gorized into four nominal variables: “living alone,” “living Methods with only a spouse,” “living with relatives other than a Purpose of the survey spouse,” and “living with a spouse and relatives. Since The purpose of the previous survey was to build the foun - independent IADL accounted for more than 80% of par- dation for the elderly to live peacefully in a familiar area ticipants, IADL was converted into a dichotomous vari- by examining the relationship between living environ- able. Social activities consisted of 16 items of three-point ment of the elderly and community. The purpose of this scales. Since their Cronbach’s α was high (0.85) and fac- study was to clarify factors contributing to home death tor analysis produced the first factor’s eigenvalue consid - by secondary data analysis. erably higher than those of other factors, variables of 16 items were summarized into a continuous variable rang- ing from 16 to 48. Participants Binary logistic regression analysis was used for both A total of 3000 people randomly extracted from 35,567 univariable and multivariable analyses. For each inde- residents of Tama City aged 65 and above in September pendent variable, a crude odds ratio and an adjusted 2014 was included in this study. The questionnaires were odds ratio with 95% confidence intervals (95% CI) were distributed and collected by mail. The number of valid calculated respectively. For the multivariable analysis responses was 1811 (valid response rate, 60.4%). all the variables were entered. Data with missing values Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 4 of 7 were excluded from the analysis. Multicollinearity among more than two stories, preference to continue to live independent variables was defined as Pearson’s correla - in the city, family type, health conditions, and afford - tion coefficient > 0.9 or variance inflation factor ≥ 4. For ability. A higher preference for home death in male the statistical analysis, IBM SPSS, ver. 20 (International participants may be due to various factors such as Business Machines Corporation, Armonk, NY) was used. paternalistic attitude, financial status, relative unsocia - bility, attachment to home, etc. Regarding family type, the results showed that those who lived with only a Ethical considerations spouse were more likely to prefer dying at home than This study was conducted as a secondary analysis of data those who lived with a spouse and other family mem- from questionnaire survey by the Tama City Medical bers (e.g., relatives). As a way of thinking of this gen- Association. The use of original data has been approved eration, it is inferred that men have a low psychological by the J. F. Oberlin University Research Ethics Com- barrier for having their spouses take care of them but mittee. The collected data were processed as linkable an uncomfortable feeling to be taken care of by other anonymous data and provided by Tama City Medical family members. These findings on the two factors were Association. in opposition to those in the abovementioned previous study by Takeu [8]. This may be due to the difference Results in study design as this study was a survey of residence Questionnaires were delivered to 3000 people, and the including healthy individuals while the study by Takeu number of valid responses with the preferred place of was a retrospective study of home deaths. death of the respondent was 1781. Breakdowns are their The analysis also revealed other factors that have not own home (n = 805, 45.2%), descendants’ home (n = 32, been examined. Regarding the type of residence, those 1.8%), house of relatives such as siblings (n = 3, 0.2%), who lived in a detached house were more likely to prefer hospitals (n = 466, 26.2%), elderly housings with support- dying at home than those who lived in a housing complex ive services (n = 67, 3.8%), intensive nursing homes for of more than two stories. According to “Results of Survey the elderly (n = 69, 3.9%), unknown (n = 285, 15.7%), and on the Senior Citizens’ Attitude toward Housing and the others (n = 54, 3.0%). Living Environment” for FY 2014 by the Cabinet Office, After excluding data with missing values and answers Government of Japan, in those aged 60 and over, the of “unknown” or “others” for the question of the pre- rates of those who were “satisfied,” “moderately satisfied,” ferred place of death, a total of 1133 responses were “moderately dissatisfied,” and “dissatisfied” with their included in the analyses in this study. Neither multicol- detached houses were 33.9, 43.6, 14.9, and 4.3%, respec- linearity nor particular outliers were observed. The Hos - tively. The rates of those who were “satisfied,” “moderately mer and Lemeshow test showed significant goodness of satisfied,” “moderately dissatisfied,” and “dissatisfied” with fit (p = 0.219). A cross table, crude odds ratios, p-value, their housing complexes were 22.5, 48.8, 16.5, and 7.2%, and adjusted odds ratios are shown in Table 1. respectively, indicating that those who lived in detached The adjusted odds ratios and 95% CIs showed that houses were significantly more satisfied with their hous - those who prefer dying at home were: (1) male partici- ing [14]. It is suggested that the tendency to be satisfied pants; (2) those who lived in detached houses, compared with detached houses leads to a preference for home with those who lived in housing complexes of more than death. two stories (with or without elevators); (3) those with a Another factor may be the ease of remodeling the preference for continued living in the city; (4) those who home when a healthy elderly person needs nursing care. lived with only a spouse (i.e., no secondary caregiver), The fact that those who lived on the first floor of a hous - compared with those who lived with a spouse and rela- ing complex required less support when going out, mak- tives; (5) those in good health; and (6) those with low ing little difference from those who lived in detached affordability. houses, may have influenced the preference for home death. In Tama City, there is a system that allows the frail Discussion elderly living on higher floors (e.g., 4th and 5th floors) of The results revealed that 47% of the participants pre - housing complexes without elevators to move to rooms ferred home death including a death at home of relatives on lower floors when they become vacant. This may also or descendants. The home death rate in 2015 was 12.7%, have influenced the preference for home death. It can be showing a large gap between patient preference for home inferred that the “preference for continued living in the death and rate of actual home death. city” may reflect the fact that they are satisfied with the The multivariable analysis excluding missing data current situation. Moving to a hospital or other medical showed that preference for home death was signifi - facility means moving out of their homes and thus may cantly affected by six factors: gender, residence with Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 5 of 7 Table 1 Cross-table, crude odds ratios, and adjusted odds ratios Item Preferred place of death Crude odds ratio p-value Adjusted odds ratio (95% CI) (95% CI) Home Institution Age (years) 65–74 301 194 1.097 (0.707–1.701) 0.703 1.102 (0.670–1.813) 75–84 298 241 0.874 (0.566–1.350) 0.429 0.824 (0.511–1.330) 85+ 58 41 Reference Reference Gender Male 489 285 1.951 (1.514–2.514) < 0.001 1.932 (1.405–2.657) Female 168 191 Reference Reference Residential district Community general support center East 128 93 0.996 (0.669–1.483) 0.368 0.815 (0.522–1.272) Community general support center West 90 59 1.104 (0.710–1.717) 0.697 0.908 (0.561–1.472) Community general support center North 82 44 1.349 (0.843–2.159) 0.869 0.956 (0.563–1.623) Community general support center Central 133 98 0.982 (0.662–1.457) 0.303 0.803 (0.528–1.219) Community general support center Tama Center 119 106 0.813 (0.548–1.206) 0.494 0.864 (0.567–1.315) Community general support center South 105 76 Reference Reference Residence Detached house 377 212 Reference Reference Housing complex of one story 79 60 0.740 (0.509–1.078) 0.250 0.777 (0.505–1.195) Housing complex of more than two stories without 144 142 0.570 (0.428–0.759) 0.002 0.586 (0.415–0.826) elevators Housing complex of more than two stories with eleva- 57 62 0.517 (0.348–0.769) 0.008 0.547 (0.351–0.854) tors Residence year ≥ 20 years 499 347 1.174 (0.896–1.538) 0.959 0.993 (0.743–1.326) < 20 years 158 129 Reference Reference Preference for continued living in the city Yes 564 382 1.492 (1.089–2.044) 0.035 1.438 (1.026–2.017) No or either way 93 94 Reference Reference Family type Living alone 78 100 0.568 (0.373–0.864) 0.910 1.028 (0.631–1.676) Living with only a spouse 355 202 1.280 (0.907–1.805) 0.024 1.519 (1.058–2.180) Living with relatives other than a spouse 121 99 0.890 (0.597–1.326) 0.147 1.403 (0.887–2.220) Living with a spouse and relatives 103 75 Reference Reference Health conditions Healthy 557 379 1.426 (1.047–1.940) 0.034 1.490 (1.031–2.153) Unhealthy 100 97 Reference Reference Certified need for long-term care None 595 434 Reference Reference Requiring support 31 26 0.870 (0.509–1.486) 0.436 1.280 (0.688–2.381) Requiring long-term care 31 16 1.413 (0.763–2.616) 0.068 1.982 (0.950–4.133) IADL Independent 544 401 Reference Reference Decreased functioning 113 75 1.111 (0.807–1.528) 0.713 1.079 (0.720–1.616) Contribution to community Yes 464 306 1.336 (1.038–1.718) 0.511 1.104 (0.822–1.481) No 193 170 Reference Reference Level of social activities (Continuous variable) 0.976 (0.955–0.997) 0.516 0.990 (0.961–1.020) Aor ff dability High 509 376 0.915 (0.687–1.218) 0.029 0.694 (0.499–0.964) Low 148 100 Reference Reference Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 6 of 7 Table 1 (continued) Item Preferred place of death Crude odds ratio p-value Adjusted odds ratio (95% CI) (95% CI) Home Institution Communication with family Inadequate 68 61 0.785 (0.544–1.135) 0.610 0.900 (0.599–1.351) Adequate 589 415 Reference Reference Communication with friends Inadequate 231 186 0.845 (0.662–1.079) 0.286 0.850 (0.631–1.146) Adequate 426 290 Reference Reference Italic cells: significant factors cause anxiety that they may not be able to continue to following two factors, the findings were in opposition live in the city. to those in the abovementioned previous study: “male Healthy individuals were more likely to prefer dying participants” and “those who lived with only a spouse at home than those who were unhealthy. Those who (i.e., no secondary caregiver).” The other four factors became ill may tend to think that they will need more have not been examined before. This may be due to the personal and nursing care in the near future and that they fact that this study was a resident survey of healthy and do not want to put the burden of nursing care on their frail elderly. families. However, their health conditions may change Future studies will include a similar survey in other in the future. Thus, such a questionnaire study does not regions to increase the generalizability of the results. provide sufficient information on how they will feel when Future studies will also analyze qualitative interview data they need nursing care in the future. to examine psychological factors of the dependent vari- Those with high affordability were more likely to pre - able (i.e., “preferred place of death”). fer dying at home than those with low affordability. The Authors’ contributions higher the affordability, the more flexible nursing care TT, HO, YO, AM, FI, and MK participated in the proposal’s design and data col- services they can choose. However, affordability of stay - lection. TT, HO carried out the data analyses and drafted the manuscript. TT, HO reviewed process of data analyses and manuscript writing. All authors read ing in a hospital or other medical facility seemed to be and approved the final manuscript. their concern. Author details Division of General Practice, Department of Internal Medicine, Kawasaki Limitations Municipal Tama Hospital, 1-30-37 Shukugawara, Tama-ku, Kasawasaki-shi, Kanagawa-ken 214-8525, Japan. International Research Center for Medical This study has several limitations. First, the response Education, Graduate School of Medicine, Faculty of Medicine, The University rate was low, and many data were excluded from the of Tokyo, Central Building 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan. multivariable analysis due to participant withdrawals, Division of Pediatrics, Kawasaki Municipal Tama Hospital, 1-30-37 Shukuga- wara, Tama-ku, Kasawasaki-shi, Kanagawa-ken 214-8525, Japan. Department etc. Second, the key question on home death to identify of Nursing, Kawasaki Municipal Tama Hospital, 1-30-37 Shukugawara, Tama-ku, the dependent variable was simple (i.e., “Where do you Kasawasaki-shi, Kanagawa-ken 214-8525, Japan. Ai Clinic Nakazawa Yuimaru prefer to die?”) without any context. Some participants Nakazawa A-1, Nakazawa, Tama-shi, Tokyo 206-0036, Japan. might feel difficulty in response to this question. Acknowledgements Not applicable. This study was presented orally at the 7th Annual Conference of Japan Conclusions Primary Care Association. Some results were changed upon reanalysis. This study identified six factors contributing to the preference for home death: (1) male participants; (2) Competing interests those who lived in detached houses, compared with The authors declare that they have no competing interests. those who lived in housing complexes of more than Availability of data and materials two stories (with or without elevators); (3) those with The datasets used and/or analysed during the current study are available from a preference for continued living in the city; (4) those the corresponding author on reasonable request. who lived with only a spouse, compared with those Consent for publication who lived with a spouse and relatives; (5) those in good Not applicable. health; and (6) those with low affordability. For the Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 7 of 7 Ethics approval and consent to participate 6. Palliative Care Meeting. About the results of “the Surveys of Palliative The study protocol was approved by J. F. Oberlin University (No. 14033). Care”; 2010. http://www.mhlw.go.jp/bunya /iryou /zaita ku/dl/07.pdf. Accessed 10 Feb 2018. Funding 7. The Review Committee on Awareness Surveys of Palliative Care, etc. There is no funds for research provided. Awareness survey report on palliative care; 2014. http://www.mhlw.go.jp/ bunya /iryou /zaita ku/dl/h2604 25-02.pdf. Accessed 10 Feb 2018. 8. Takeu R. A review of articles about factors association with death at home Publisher’s Note and death at hospital since 1990 in japan. Nihon Chiiki Kango Gakkai Shi. Springer Nature remains neutral with regard to jurisdictional claims in pub- 2008;11(1):87–92. lished maps and institutional affiliations. 9. Hattori A, Uemura K, Masuda Y, Mogi N, Naito M, Iguchi A. Factors con- tributing to dying at home in elderly patients who received home care Received: 22 March 2018 Accepted: 5 July 2018 service. Nihon Ronen Igakkai Zasshi. 2001;38(3):399–404. 10. Suzuki H, Suzuki S. Factors for dying at home in home care for terminally- ill cancer patients. Japan J Prim Care. 2005;28(4):251–60. 11. Sugikoto S, Koga T, Nishigaki C. Problems of home medical treatment in terminal medical care. Bull Soc Med. 2009;27(1):9–16. References 12. Tama City. Elderly health care and public aid project (insured long-term 1. Ministry of Health, Labor and Welfare. Annual vital statistics report (Final); care service plans) for 2015–2017; 2015. http://www.city.tama.lg.jp/00000 2015. http://www.mhlw.go.jp/touke i/saiki n/hw/jinko u/kakut ei15/. 03472 .html. Accessed 10 Feb 2018. Accessed 10 Feb 2018. 13. Tama City Medical Association. Research project on multi-sectoral 2. Cabinet Office, Government of Japan. Trends in deaths. http://www8.cao. collaboration of medical, nursing and preventive care in comprehen- go.jp/kisei -kaika ku/kaigi /meeti ng/2013/wg4/kenko /15122 4/item2 -2-2. sive community care for home care promotion: a report on long-term pdf. Accessed 10 Feb 2018. preventative care and disaster support for the elderly. 2015. p. 1–215. 3. Shinya Matsuda. The results of the study by the working group for the 14. Cabinet Office, Government of Japan. Survey on the senior citizens’ analysis and discussion of medical and nursing care information—about attitude toward housing and the living environment for FY 2014. http:// the estimated hospital bed capacity by medical care function for 2025. www8.cao.go.jp/koure i/ishik i/h26/sougo u/zenta i/index .html. Accessed http://www.kante i.go.jp/jp/singi /shaka ihosh oukai kaku/chous akai_dai5/ 10 Feb 2018. siryo u1.pdf. Accessed 10 Feb 2018. 4. Gomes B, Higginson IJ. Factors influencing death at home in terminally ill patients with cancer: systematic review. BMJ. 2006;332(7540):515–21. 5. Wahid AS, Sayma M, Jamshaid S, Kerwat D, Oyewole F, Saleh D, et al. Barriers and facilitators influencing death at home: a meta-ethnography. Palliat Med. 2017;32(2):314–28. 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Population-based survey regarding factors contributing to expectation for death at home

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Springer Journals
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2018 The Author(s)
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1447-056X
DOI
10.1186/s12930-018-0044-z
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Abstract

Background: In 2015 in Japan 12.7% of people die at home. Since the government has no policy to increase the number of hospital beds, at-home deaths should inevitably increase in the near future. Previous researches regarding expected place of death have focused on end-of-life patients. The aim of this study is to clarify the percentage and factors of senior people who expect at-home deaths whether they are end-of-life or not. Methods: Using cross-sectional questionnaire survey data which had been taken by a research group with the sup- port from Tama City Medical Association ( Tokyo) in 2014, univariable and multivariable logistic regression analyses were conducted to identify associations among factors. The dependent variable was the expected site of death and other factors were set as independent variables. Results: Of 1781 respondents, 46.5% expected at-home deaths. Data from 1133 people were analyzed and 46.5% of those wanted at-home deaths. Factors significantly associated with expectation of at-home death were men, stand- alone houses for dwelling, expectation to continue life in Tama city, twosome life with the spouse, healthiness, and economic challenge. Conclusion: Percentage of those who expected at-home deaths was much higher than the latest percentage of at- home deaths. Some factors associated with expectation of at-home deaths in this study have never been discussed. Keywords: Terminal care, Surveys and questionnaires, Multivariable analyses or nursing homes for the elderly increased from 2.8% in Background 2005 to 8.6% in 2015, showing a considerable increase [1] As Japan becomes an aging society with declining birth (Fig. 1). In addition, according to the Working Group for rates and increasing mortality rates, the gap between the Analysis and Discussion of Medical and Nursing Care preferred and actual place of death is currently an impor- Information, in the Expert Panels on the Promotion of tant issue in medical care and welfare. It is estimated that Reforms with Medical and Nursing Care Information of the number of annual deaths in Japan will increase from the National Council on Social Security System Reform, 1.29 million in 2015 [1] to 1.67 million in 2040 [2]. In the hospital bed capacity in 2013 was 1.35 million, and the 1950s, homes accounted for 82.5% of places of death. In estimated hospital bed capacity by medical care function 2015, homes accounted for only 12.7% of places of death in 2025 is predicted to be 1.15–1.19 million [3]. There is while hospitals accounted for 78.4%. On the other hand, no plan to increase hospital bed capacity in the future. the idea of ending life in a familiar place has become It can be inferred that more people will die at home or common in the last decade. Home deaths increased in care facilities if there is no reduction in hospital stay, slightly from 12.2% in 2005 to 12.7% in 2015. The death among other aspects. Thus, it is important to explore fac rates for those who died at long-term care health facilities - tors that affect place of death in predicting the trend of medical and nursing care. *Correspondence: tsuchidatomoya@gmail.com A systematic review of factors influencing death at Division of General Practice, Department of Internal Medicine, Kawasaki home in terminally ill patients with cancer identified the Municipal Tama Hospital, 1-30-37 Shukugawara, Tama-ku, Kasawasaki-shi, Kanagawa-ken 214-8525, Japan following items as factors strongly associated with home Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 2 of 7 Fig. 1 Trends in deaths by place of death. Deaths at long-term care health facilities before 1989 and those at nursing homes for the elderly before 1995 are included in the category of home deaths. Excerpt from Trends in deaths by place of death. Annual Vital Statistics Report (Final) 2015, Ministry of Health, Labor and Welfare death: patients’ low functional status, patients’ prefer- 27.2, 52.4, and 10.9% in 2008, respectively, and the rates ences, use and intensity of home care, living arrange- for those who wanted to spend a certain period of time ments, and extended family support [4]. In addition, at home or die at home slightly increased. However, this meta-ethnography in Wahid et  al. lists the following survey showed that those who wanted to die at home items as barriers to home death: lack of knowledge, skills accounted for only 10% while many people preferred to of and support among informal carers and healthcare die in a medical institution. professionals, informal carer and family burden, recog- In a 2014 survey by the Review Committee on Aware- nizing death, inadequacy of processes such as advance ness Surveys of Palliative Care, etc., five types of patients care planning and discharge, and inherent patient diffi - answered to questions about preferred place of death. culties due to medical conditions or social circumstances. Those in a coma with progressive weakness for more than It also lists the following items as factors promoting half a year after a traffic accident and end-stage cancer home death: support for patients and healthcare profes- patients who had good appetite and judgement without sionals, skilled staff, coordination and effective commu - pain accounted for 10.3 and 71.7% of those who opted nication [5]. to spend their last years of life at home, respectively [7], Regarding the situation in Japan, the results of “the suggesting that this type of survey shows different results Surveys of Palliative Care” 1998 by “the Palliative Care depending on contexts. Meeting” showed that those who wanted to be hospital- The literature review by Takeu [8] identified the follow - ized in a medical institution or palliative care ward that ing items as factors commonly observed in home care they have visited as soon as possible accounted for 32.5%; patients who prefer home death: female, elderly, without those who wanted to receive home care and, if necessary, pain, without breathing difficulties, bedridden, and pref - be hospitalized in a medical institution or palliative care erence for home death. It identified the following items ward accounted for 48.7%; and those who preferred to die as factors commonly observed in families and caregivers: at homes accounted for 9.0% [6]. These rates changed to secondary caregivers included, non-spouse or child, and Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 3 of 7 preference for home death. It also identified the following Questionnaire items as factors commonly observed in medical care and The questionnaire included the following items: (1) age, home care services: “a visiting physician available, attend- sex, height, and weight; (2) residential district (one dis- ing physician’s or clinic’s positive attitude toward home trict is selected from 26 districts of Tama city); (3) resi- death, use of home care services, psychological support dence: detached houses, housing complexes of (1st or from the family.” Hattori et  al. stated that a decrease in 2nd or upper floor with/without elevator); (4) year of res - activities of daily living (ADL) 1  month before death is idence; (5) preference to continue to live; (6) family type; also a factor contributing to home death. They identi - (7) health conditions; (8) certified need for long-term fied the following items as barriers to home death: sense care; (9) instrumental ADL (IADL); (10) contribution to of burden felt by families, anxiety at the time of sudden community; (11) level of social activities; (12) affordabil - change, and anxiety about hospitalization at the time of ity; (13) families and relatives, the frequency of commu- sudden change [9]. Suzuki et al. listed the following items nication with friends; and (14) preferred place of death as factors enabling home death: the acceptance of the (Question is “Where do you want to die? Please circle home death by the family, patient preference for home one item “medical institution, home, family’s home, facil- death, presence or absence of family caregivers, introduc- ities for the elderly, facilities covered by long-term care tion of home care nursing, and relief of physical pain [10]. insurance, don’t know, others”). According to Sugikoto et al. in most cases, the major fac- tor contributing to the decision on the place of death was “patients’ preferences” [11]. Statistical analysis Tama City is located in the south-west suburb in Univariable and multivariable analyses were performed Tokyo. It is a unique city whose population has dramati- with preferred place of death as a dependent variable and cally increased within 30  years from less than 10,000 in other factors as independent variables. Regarding the 1960 to 140,000 in 1990 with the development of Tama dependent variables, preferred place of death was cat- New Town. Many residents are baby boomers who relo- egorized into a dichotomous variable: “home death” (i.e., cated into Tama in their thirties and forties in the late “home” or “family’s home”) and “non-home death” (i.e., 1970s and 1980s. However, the rate of aged 65 and above “medical institutions such as hospitals,” “elderly hous- in Tama City is expected to increase rapidly from 25.4% ing with supportive services,” or “facility such as special in 2015 to 32.6% in 2025 [12]. Thus, we thought it would elderly nursing home”). Responses of “do not know” and be possible to predict the near future of Japan by analyz- “other” are excluded from the analysis. ing the data on the preference for home death in Tama Changes were made to the independent variables city. before the analysis. Ages were categorized into three The purpose of this study was to examine the charac - groups based on age (i.e., 65–74, 75–84, and 85+ years). teristics of those who prefer to die at home by analyz- Residential areas were categorized into six nominal varia- ing data from a questionnaire survey [13] in residents of bles by the jurisdiction of six community general support Tama City aged 65 and above. centers. Residence year was converted into a dichoto- mous variable of ≥ 20 years or not. Family type was cate- gorized into four nominal variables: “living alone,” “living Methods with only a spouse,” “living with relatives other than a Purpose of the survey spouse,” and “living with a spouse and relatives. Since The purpose of the previous survey was to build the foun - independent IADL accounted for more than 80% of par- dation for the elderly to live peacefully in a familiar area ticipants, IADL was converted into a dichotomous vari- by examining the relationship between living environ- able. Social activities consisted of 16 items of three-point ment of the elderly and community. The purpose of this scales. Since their Cronbach’s α was high (0.85) and fac- study was to clarify factors contributing to home death tor analysis produced the first factor’s eigenvalue consid - by secondary data analysis. erably higher than those of other factors, variables of 16 items were summarized into a continuous variable rang- ing from 16 to 48. Participants Binary logistic regression analysis was used for both A total of 3000 people randomly extracted from 35,567 univariable and multivariable analyses. For each inde- residents of Tama City aged 65 and above in September pendent variable, a crude odds ratio and an adjusted 2014 was included in this study. The questionnaires were odds ratio with 95% confidence intervals (95% CI) were distributed and collected by mail. The number of valid calculated respectively. For the multivariable analysis responses was 1811 (valid response rate, 60.4%). all the variables were entered. Data with missing values Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 4 of 7 were excluded from the analysis. Multicollinearity among more than two stories, preference to continue to live independent variables was defined as Pearson’s correla - in the city, family type, health conditions, and afford - tion coefficient > 0.9 or variance inflation factor ≥ 4. For ability. A higher preference for home death in male the statistical analysis, IBM SPSS, ver. 20 (International participants may be due to various factors such as Business Machines Corporation, Armonk, NY) was used. paternalistic attitude, financial status, relative unsocia - bility, attachment to home, etc. Regarding family type, the results showed that those who lived with only a Ethical considerations spouse were more likely to prefer dying at home than This study was conducted as a secondary analysis of data those who lived with a spouse and other family mem- from questionnaire survey by the Tama City Medical bers (e.g., relatives). As a way of thinking of this gen- Association. The use of original data has been approved eration, it is inferred that men have a low psychological by the J. F. Oberlin University Research Ethics Com- barrier for having their spouses take care of them but mittee. The collected data were processed as linkable an uncomfortable feeling to be taken care of by other anonymous data and provided by Tama City Medical family members. These findings on the two factors were Association. in opposition to those in the abovementioned previous study by Takeu [8]. This may be due to the difference Results in study design as this study was a survey of residence Questionnaires were delivered to 3000 people, and the including healthy individuals while the study by Takeu number of valid responses with the preferred place of was a retrospective study of home deaths. death of the respondent was 1781. Breakdowns are their The analysis also revealed other factors that have not own home (n = 805, 45.2%), descendants’ home (n = 32, been examined. Regarding the type of residence, those 1.8%), house of relatives such as siblings (n = 3, 0.2%), who lived in a detached house were more likely to prefer hospitals (n = 466, 26.2%), elderly housings with support- dying at home than those who lived in a housing complex ive services (n = 67, 3.8%), intensive nursing homes for of more than two stories. According to “Results of Survey the elderly (n = 69, 3.9%), unknown (n = 285, 15.7%), and on the Senior Citizens’ Attitude toward Housing and the others (n = 54, 3.0%). Living Environment” for FY 2014 by the Cabinet Office, After excluding data with missing values and answers Government of Japan, in those aged 60 and over, the of “unknown” or “others” for the question of the pre- rates of those who were “satisfied,” “moderately satisfied,” ferred place of death, a total of 1133 responses were “moderately dissatisfied,” and “dissatisfied” with their included in the analyses in this study. Neither multicol- detached houses were 33.9, 43.6, 14.9, and 4.3%, respec- linearity nor particular outliers were observed. The Hos - tively. The rates of those who were “satisfied,” “moderately mer and Lemeshow test showed significant goodness of satisfied,” “moderately dissatisfied,” and “dissatisfied” with fit (p = 0.219). A cross table, crude odds ratios, p-value, their housing complexes were 22.5, 48.8, 16.5, and 7.2%, and adjusted odds ratios are shown in Table 1. respectively, indicating that those who lived in detached The adjusted odds ratios and 95% CIs showed that houses were significantly more satisfied with their hous - those who prefer dying at home were: (1) male partici- ing [14]. It is suggested that the tendency to be satisfied pants; (2) those who lived in detached houses, compared with detached houses leads to a preference for home with those who lived in housing complexes of more than death. two stories (with or without elevators); (3) those with a Another factor may be the ease of remodeling the preference for continued living in the city; (4) those who home when a healthy elderly person needs nursing care. lived with only a spouse (i.e., no secondary caregiver), The fact that those who lived on the first floor of a hous - compared with those who lived with a spouse and rela- ing complex required less support when going out, mak- tives; (5) those in good health; and (6) those with low ing little difference from those who lived in detached affordability. houses, may have influenced the preference for home death. In Tama City, there is a system that allows the frail Discussion elderly living on higher floors (e.g., 4th and 5th floors) of The results revealed that 47% of the participants pre - housing complexes without elevators to move to rooms ferred home death including a death at home of relatives on lower floors when they become vacant. This may also or descendants. The home death rate in 2015 was 12.7%, have influenced the preference for home death. It can be showing a large gap between patient preference for home inferred that the “preference for continued living in the death and rate of actual home death. city” may reflect the fact that they are satisfied with the The multivariable analysis excluding missing data current situation. Moving to a hospital or other medical showed that preference for home death was signifi - facility means moving out of their homes and thus may cantly affected by six factors: gender, residence with Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 5 of 7 Table 1 Cross-table, crude odds ratios, and adjusted odds ratios Item Preferred place of death Crude odds ratio p-value Adjusted odds ratio (95% CI) (95% CI) Home Institution Age (years) 65–74 301 194 1.097 (0.707–1.701) 0.703 1.102 (0.670–1.813) 75–84 298 241 0.874 (0.566–1.350) 0.429 0.824 (0.511–1.330) 85+ 58 41 Reference Reference Gender Male 489 285 1.951 (1.514–2.514) < 0.001 1.932 (1.405–2.657) Female 168 191 Reference Reference Residential district Community general support center East 128 93 0.996 (0.669–1.483) 0.368 0.815 (0.522–1.272) Community general support center West 90 59 1.104 (0.710–1.717) 0.697 0.908 (0.561–1.472) Community general support center North 82 44 1.349 (0.843–2.159) 0.869 0.956 (0.563–1.623) Community general support center Central 133 98 0.982 (0.662–1.457) 0.303 0.803 (0.528–1.219) Community general support center Tama Center 119 106 0.813 (0.548–1.206) 0.494 0.864 (0.567–1.315) Community general support center South 105 76 Reference Reference Residence Detached house 377 212 Reference Reference Housing complex of one story 79 60 0.740 (0.509–1.078) 0.250 0.777 (0.505–1.195) Housing complex of more than two stories without 144 142 0.570 (0.428–0.759) 0.002 0.586 (0.415–0.826) elevators Housing complex of more than two stories with eleva- 57 62 0.517 (0.348–0.769) 0.008 0.547 (0.351–0.854) tors Residence year ≥ 20 years 499 347 1.174 (0.896–1.538) 0.959 0.993 (0.743–1.326) < 20 years 158 129 Reference Reference Preference for continued living in the city Yes 564 382 1.492 (1.089–2.044) 0.035 1.438 (1.026–2.017) No or either way 93 94 Reference Reference Family type Living alone 78 100 0.568 (0.373–0.864) 0.910 1.028 (0.631–1.676) Living with only a spouse 355 202 1.280 (0.907–1.805) 0.024 1.519 (1.058–2.180) Living with relatives other than a spouse 121 99 0.890 (0.597–1.326) 0.147 1.403 (0.887–2.220) Living with a spouse and relatives 103 75 Reference Reference Health conditions Healthy 557 379 1.426 (1.047–1.940) 0.034 1.490 (1.031–2.153) Unhealthy 100 97 Reference Reference Certified need for long-term care None 595 434 Reference Reference Requiring support 31 26 0.870 (0.509–1.486) 0.436 1.280 (0.688–2.381) Requiring long-term care 31 16 1.413 (0.763–2.616) 0.068 1.982 (0.950–4.133) IADL Independent 544 401 Reference Reference Decreased functioning 113 75 1.111 (0.807–1.528) 0.713 1.079 (0.720–1.616) Contribution to community Yes 464 306 1.336 (1.038–1.718) 0.511 1.104 (0.822–1.481) No 193 170 Reference Reference Level of social activities (Continuous variable) 0.976 (0.955–0.997) 0.516 0.990 (0.961–1.020) Aor ff dability High 509 376 0.915 (0.687–1.218) 0.029 0.694 (0.499–0.964) Low 148 100 Reference Reference Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 6 of 7 Table 1 (continued) Item Preferred place of death Crude odds ratio p-value Adjusted odds ratio (95% CI) (95% CI) Home Institution Communication with family Inadequate 68 61 0.785 (0.544–1.135) 0.610 0.900 (0.599–1.351) Adequate 589 415 Reference Reference Communication with friends Inadequate 231 186 0.845 (0.662–1.079) 0.286 0.850 (0.631–1.146) Adequate 426 290 Reference Reference Italic cells: significant factors cause anxiety that they may not be able to continue to following two factors, the findings were in opposition live in the city. to those in the abovementioned previous study: “male Healthy individuals were more likely to prefer dying participants” and “those who lived with only a spouse at home than those who were unhealthy. Those who (i.e., no secondary caregiver).” The other four factors became ill may tend to think that they will need more have not been examined before. This may be due to the personal and nursing care in the near future and that they fact that this study was a resident survey of healthy and do not want to put the burden of nursing care on their frail elderly. families. However, their health conditions may change Future studies will include a similar survey in other in the future. Thus, such a questionnaire study does not regions to increase the generalizability of the results. provide sufficient information on how they will feel when Future studies will also analyze qualitative interview data they need nursing care in the future. to examine psychological factors of the dependent vari- Those with high affordability were more likely to pre - able (i.e., “preferred place of death”). fer dying at home than those with low affordability. The Authors’ contributions higher the affordability, the more flexible nursing care TT, HO, YO, AM, FI, and MK participated in the proposal’s design and data col- services they can choose. However, affordability of stay - lection. TT, HO carried out the data analyses and drafted the manuscript. TT, HO reviewed process of data analyses and manuscript writing. All authors read ing in a hospital or other medical facility seemed to be and approved the final manuscript. their concern. Author details Division of General Practice, Department of Internal Medicine, Kawasaki Limitations Municipal Tama Hospital, 1-30-37 Shukugawara, Tama-ku, Kasawasaki-shi, Kanagawa-ken 214-8525, Japan. International Research Center for Medical This study has several limitations. First, the response Education, Graduate School of Medicine, Faculty of Medicine, The University rate was low, and many data were excluded from the of Tokyo, Central Building 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan. multivariable analysis due to participant withdrawals, Division of Pediatrics, Kawasaki Municipal Tama Hospital, 1-30-37 Shukuga- wara, Tama-ku, Kasawasaki-shi, Kanagawa-ken 214-8525, Japan. Department etc. Second, the key question on home death to identify of Nursing, Kawasaki Municipal Tama Hospital, 1-30-37 Shukugawara, Tama-ku, the dependent variable was simple (i.e., “Where do you Kasawasaki-shi, Kanagawa-ken 214-8525, Japan. Ai Clinic Nakazawa Yuimaru prefer to die?”) without any context. Some participants Nakazawa A-1, Nakazawa, Tama-shi, Tokyo 206-0036, Japan. might feel difficulty in response to this question. Acknowledgements Not applicable. This study was presented orally at the 7th Annual Conference of Japan Conclusions Primary Care Association. Some results were changed upon reanalysis. This study identified six factors contributing to the preference for home death: (1) male participants; (2) Competing interests those who lived in detached houses, compared with The authors declare that they have no competing interests. those who lived in housing complexes of more than Availability of data and materials two stories (with or without elevators); (3) those with The datasets used and/or analysed during the current study are available from a preference for continued living in the city; (4) those the corresponding author on reasonable request. who lived with only a spouse, compared with those Consent for publication who lived with a spouse and relatives; (5) those in good Not applicable. health; and (6) those with low affordability. For the Tsuchida et al. Asia Pac Fam Med (2018) 17:7 Page 7 of 7 Ethics approval and consent to participate 6. Palliative Care Meeting. About the results of “the Surveys of Palliative The study protocol was approved by J. F. Oberlin University (No. 14033). Care”; 2010. http://www.mhlw.go.jp/bunya /iryou /zaita ku/dl/07.pdf. Accessed 10 Feb 2018. Funding 7. The Review Committee on Awareness Surveys of Palliative Care, etc. There is no funds for research provided. Awareness survey report on palliative care; 2014. http://www.mhlw.go.jp/ bunya /iryou /zaita ku/dl/h2604 25-02.pdf. Accessed 10 Feb 2018. 8. Takeu R. A review of articles about factors association with death at home Publisher’s Note and death at hospital since 1990 in japan. Nihon Chiiki Kango Gakkai Shi. Springer Nature remains neutral with regard to jurisdictional claims in pub- 2008;11(1):87–92. lished maps and institutional affiliations. 9. Hattori A, Uemura K, Masuda Y, Mogi N, Naito M, Iguchi A. Factors con- tributing to dying at home in elderly patients who received home care Received: 22 March 2018 Accepted: 5 July 2018 service. Nihon Ronen Igakkai Zasshi. 2001;38(3):399–404. 10. Suzuki H, Suzuki S. Factors for dying at home in home care for terminally- ill cancer patients. Japan J Prim Care. 2005;28(4):251–60. 11. Sugikoto S, Koga T, Nishigaki C. Problems of home medical treatment in terminal medical care. Bull Soc Med. 2009;27(1):9–16. References 12. Tama City. Elderly health care and public aid project (insured long-term 1. Ministry of Health, Labor and Welfare. Annual vital statistics report (Final); care service plans) for 2015–2017; 2015. http://www.city.tama.lg.jp/00000 2015. http://www.mhlw.go.jp/touke i/saiki n/hw/jinko u/kakut ei15/. 03472 .html. Accessed 10 Feb 2018. Accessed 10 Feb 2018. 13. Tama City Medical Association. Research project on multi-sectoral 2. Cabinet Office, Government of Japan. Trends in deaths. http://www8.cao. collaboration of medical, nursing and preventive care in comprehen- go.jp/kisei -kaika ku/kaigi /meeti ng/2013/wg4/kenko /15122 4/item2 -2-2. sive community care for home care promotion: a report on long-term pdf. Accessed 10 Feb 2018. preventative care and disaster support for the elderly. 2015. p. 1–215. 3. Shinya Matsuda. The results of the study by the working group for the 14. Cabinet Office, Government of Japan. Survey on the senior citizens’ analysis and discussion of medical and nursing care information—about attitude toward housing and the living environment for FY 2014. http:// the estimated hospital bed capacity by medical care function for 2025. www8.cao.go.jp/koure i/ishik i/h26/sougo u/zenta i/index .html. Accessed http://www.kante i.go.jp/jp/singi /shaka ihosh oukai kaku/chous akai_dai5/ 10 Feb 2018. siryo u1.pdf. Accessed 10 Feb 2018. 4. Gomes B, Higginson IJ. Factors influencing death at home in terminally ill patients with cancer: systematic review. BMJ. 2006;332(7540):515–21. 5. Wahid AS, Sayma M, Jamshaid S, Kerwat D, Oyewole F, Saleh D, et al. Barriers and facilitators influencing death at home: a meta-ethnography. Palliat Med. 2017;32(2):314–28. 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Published: Dec 1, 2018

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