1286 IS VIRTUAL ADVANCE CARE PLANNING SIMULATION AS EFFECTIVE AS FACE-TO-FACE LEARNING?

Introduction

Advance care planning (ACP) is about what matters to patients, enabling their wishes to be respected, even when they become unable to engage in decision-making. Evidence shows ACP improves end of life care for patients and reduces relatives’ bereavement reactions (Detering KM et al. BMJ. 2010; 340:1345). A simulation course for multidisciplinary healthcare professionals, using actors, was developed to improve understanding of ACP, and confidence in having these conversations. In response to the COVID-19 pandemic, the course was adapted to an online format.

Method

Participants were asked about their ACP confidence and understanding pre- and post-course, using a Likert scale (1-Not at all to 5-Very confident). Data between 2018-2022 was analysed to compare face-to-face and online course responses. Free-text responses to ‘How do you feel about attending the course online?’ were analysed qualitatively. Ethics approval was not required.

Results

Five face-to-face and five virtual sessions trained 128 and 133 attendees respectively. Confidence in having ACP discussions improved significantly following the course in both cohorts; from a mean Likert rating of 2.77 (95% CI 2.60-2.94, n=132) to 4.11 following face-to-face training (95% CI 3.97-4.25, n=128), and from 2.79 (95% CI 2.66-2.91, n=149) to 4.11 following the online course (95% CI 4.01-4.21, n=133). Additionally, 97% (n=132) of face-to-face attendees and 99.2% (n=133) of virtual attendees said their practice would change because of the course. Following the training, 100% of participants across both cohorts reported that they ‘fully understood’ what was meant by ACP, from a baseline of 77.3% (n=132) in the face-to-face cohort and 81.9% (n=149) of virtual participants. Free-text analysis highlighted the convenience of attending online (n=22, 21%), and only a minority reported technical difficulties (n=8,8%).

Conclusion

This course was successfully adapted to a virtual format, improving participants’ ACP confidence and understanding as effectively as in-person training, whilst being more accessible.

Position paper on undergraduate Palliative Medicine education for doctors in South Africa

Background

Basic palliative care teaching should be included in training curricula for health care providers (HCPs) at all levels of the health service to ensure that the goal set by the South African (SA) National Policy Framework and Strategy for Palliative Care, to have an adequate number of appropriately trained HCPs in South Africa, is achieved. Furthermore, palliative learning objectives for nurses and doctors should be standardised. Many SA medical schools have integrated elements of Palliative Medicine (PM) teaching into undergraduate medical training programmes for doctors; however, the degree of integration varies widely, and consensus and standardisation of the content, structure and delivery of such PM training programmes are not yet a reality.

Aim

This joint position paper aims to describe the current state of undergraduate medical PM teaching in South Africa and define the PM competencies required for an SA generalist doctor.

Setting

Palliative Medicine programme leads and teachers from eight medical schools in South Africa.

Methods

A survey exploring the structure, organisation and content of the respective medical undergraduate PM programmes was distributed to PM programme leads and teachers.

Results

Responses were received from seven medical schools. Through a process of iterative review, competencies were defined and further grouped according to suitability for the pre-clinical and clinical components of the curriculum.

Conclusion

Through mapping out these competencies in a spiralled medical curriculum, the authors hope to provide guidance to medical curriculum designers to effectively integrate PM teaching and learning into current curricula in line with the goals of the SA National Policy Framework and Strategy on Palliative Care (NPFSPC).

A Delphi study to guide the development of a clinical indicator tool for palliative care in South Africa

Background

The South African National Policy Framework and Strategy on Palliative Care (NPFSPC) recommends that when integrating palliative care (PC) into the health system, a PC indicators tool should be used to guide clinicians to recognise a patient who should receive PC. The policy document recommends ‘a simple screening tool developed for use in South Africa that would assist healthcare professionals (HCPs) to recognise patients who may have unmet palliative care needs’.

Aim

This research study sought to develop South African consensus on indicators for PC to assist clinicians to recognise a patient in need of PC.

Setting

The South African healthcare setting.

Methods

A Delphi study was considered suitable as a methodology to develop consensus. The methodology was based on the Conducting and REporting of DElphi studies (CREDES) guidance on Delphi studies to ensure rigour and transparency in conducting and reporting. Six different Delphi rounds were used to develop consensus. Each round allowed participants to anonymously rate statements with predefined rating scales.

Results

Cognisant of the disparities in healthcare provision and access to equitable healthcare in South Africa, the expert advisory group recommended, especially for South Africa, that ‘this tool is for deteriorating patients with an advanced life-limiting illness where all available and appropriate management for underlying illnesses and reversible complications has been offered’. The expert advisory group felt that disease-specific indicators should be described before the general indicators in the South African indicators tool, so all users of the tool orientate themselves to the disease categories first. This study included three new domains to address the South African context: trauma, infectious diseases and haematological diseases. General indicators for PC aligned with the original Supportive and Palliative Care Indicators Tool (SPICT) tool.

Conclusion

The Supportive and Palliative Care Indicators Tool for South Africa (SPICT^TM-SA) is a simple screening tool for South Africa that may assist HCPs to recognise patients who may have unmet PC needs.

467 FRAILTY IN SITU SIMULATION

Introduction

The ability to recognise and manage frailty and its associated presentations is variable among acute hospital staff. Patients living with frailty who are admitted to hospital are more likely to suffer adverse effects than those without. We created an inter-professional in-situ simulation programme designed to improve recognition and management of frailty and its common adverse events. The programme objectives align with recommendations from the British Geriatric Society’s ‘Frailty Hub’ and Royal College of Physicians’ ‘Acute Care Toolkit’ for frailty.

Method

Over a two month period, seven sessions were completed on the Older Persons Unit (OPU) at St Thomas’ Hospital. These comprised a simulated scenario followed by facilitated debrief—including technical skills and human factors highlighted by the scenario. Quantitative data was collected through pre and post session questionnaires using the Human Factors Skills for Healthcare Instrument (HuFSHI) and frailty based questions. Post session qualitative data was also collected.

Results

30 participants attended the sessions (nursing, medical and allied health professional). All participants completing the post course questionnaire found the sessions useful. When comparing pre and post session data, participant confidence in 10/12 sections of the HuFSHI and 8/9 frailty based questions demonstrated improvement. The qualitative data showed common learning themes around improved communication, teamwork and escalation. Participants found that the sessions were a valuable ‘opportunity to reflect’ and ‘debrief’, and learn together as a multidisciplinary team.

Conclusion

In-situ simulation is an effective tool for improving knowledge and confidence in managing frail patients. It increases awareness and understanding of human factors, which are key to the multidisciplinary approach frail patients require. The course is being expanded across the OPU and now has funding for a departmental manikin. The programme can be disseminated to other units to help improve the care and safety of those with frailty in hospital.

Shaping the Future of Probiotics and Prebiotics

Recent and ongoing developments in microbiome science are enabling new frontiers of research for probiotics and prebiotics. Novel types, mechanisms, and applications currently under study have the potential to change scientific understanding as well as nutritional and healthcare applications of these interventions. The expansion of related fields of microbiome-targeted interventions, and an evolving landscape for implementation across regulatory, policy, prescriber, and consumer spheres, portends an era of significant change. In this review we examine recent, emerging, and anticipated trends in probiotic and prebiotic science, and create a vision for broad areas of developing influence in the field.

Primary palliative care competency framework for primary care and family physicians in India-Collaborative work by Indian Association of Palliative Care and Academy of Family Physicians of India

The discrepancy in the demand for palliative care and distribution of specialist palliative care services will force patients to be eventually cared for by primary care/family physicians in the community. This will necessitate primary care/family physicians to equip themselves with knowledge and skills of primary palliative care. Indian National Health Policy (2017) recommended the creation of continuing education programs as a method to empower primary care/family physicians. With this intention, a taskforce was convened for incorporating primary palliative care into family/primary care practice. The taskforce comprising of National and International faculties from Palliative Care and Family Medicine published a position paper in 2018 and subsequently brainstormed on the competency framework required for empowering primary care/family physicians. The competencies were covered under the following domains: knowledge, skills and attitude, ethical and legal aspects, communication and team work. The competency framework will be presented to the National Board of Examinations recommending to be incorporated in the DNB curriculum for Family Medicine.

The induction of core pluripotency master regulators in cancers defines poor clinical outcomes and treatment resistance

Stem cell characteristics have been associated with treatment resistance and poor prognosis across many cancer types. The ability to induce and regulate the pathways that sustain these characteristic hallmarks of lethal cancers in a novel in vitro model would greatly enhance our understanding of cancer progression and treatment resistance. In this work, we present such a model, based simply on applying standard pluripotency/embryonic stem cell media alone. Core pluripotency stem cell master regulators (OCT4, SOX2 and NANOG) along with epithelial–mesenchymal transition (EMT) markers (Snail, Slug, vimentin and N-cadherin) were induced in human prostate, breast, lung, bladder, colorectal, and renal cancer cells. RNA sequencing revealed pathways activated by pluripotency inducing culture that were shared across all cancers examined. These pathways highlight a potential core mechanism of treatment resistance. With a focus on prostate cancer, the culture-based induction of core pluripotent stem cell regulators was shown to promote survival in castrate conditions—mimicking first line treatment resistance with hormonal therapies. This acquired phenotype was shown to be mediated through the upregulation of iodothyronine deiodinase DIO2, a critical modulator of the thyroid hormone signalling pathway. Subsequent inhibition of DIO2 was shown to supress expression of prostate specific antigen, the cardinal clinical biomarker of prostate cancer progression and highlighted a novel target for clinical translation in this otherwise fatal disease. This study identifies a new and widely accessible simple preclinical model to recreate and explore underpinning pathways of lethal disease and treatment resistance.

Joint position statement Indian Association of Palliative Care and Academy of Family Physicians of India - The way forward for developing community-based palliative care program throughout India: Policy, education, and service delivery considerations

Purpose:

This joint position statement, by the Indian Association of Palliative Care (IAPC) and Academy of Family Physicians of India (AFPI), proposes to address gaps in palliative care provision in the country by developing a community-based palliative care model that will empower primary care physicians to provide basic palliative care.

Evidence:

India ranks very poorly, 67th of 80 countries in the quality of death index. Two-thirds of patients who die need palliative care and many such patients spend the last hours of life in the Intensive care unit. The Indian National Health Policy (NHP) 2017 and other international bodies endorse palliative care as an essential health-care service component. NHP 2017 also recommends development of distance and continuing education options for general practitioners to upgrade their skills to provide timely interventions and avoid unnecessary referrals.

Methods:

A taskforce was formed with Indian and International expertise in palliative care and family medicine to develop this paper including an open conference at the IAPC conference 2017, agreement of a formal liaison between IAPC and AFPI and wide consultation leading to the development of this position paper aimed at supporting integration, networking, and joint working between palliative care specialists and generalists. The WHO model of taking a public health approach to palliative care was used as a framework for potential developments; policy support, education and training, service development, and availability of appropriate medicines.

Recommendations:

This taskforce recommends the following (1) Palliative care should be integrated into all levels of care including primary care with clear referral pathways, networking between palliative care specialist centers and family medicine physicians and generalists in community settings, to support education and clinical services. (2) Implement the recommendations of NHP 2017 to develop services and training programs for upskilling of primary care doctors in public and private sector. (3) Include palliative care as a mandatory component in the undergraduate (MBBS) and postgraduate curriculum of family physicians. (4) Improve access to necessary medications in urban and rural areas. (5) Provide relevant in-service training and support for palliative care to all levels of service providers including primary care and community staff. (6) Generate public awareness about palliative care and empower the community to identify those with chronic disease and provide support for those choosing to die at home.

What's next for the Ju/'hoansi? James Suzman Bloomsbury USA, 2017. 320 pp

A community of Kalahari hunter-gatherers struggles to find their way in a changing world

Waiting and hoping: a phenomenographic study of the experiences of boarded patients in the emergency department

AIMS AND OBJECTIVES

To understand the experiences and concerns of patients in the emergency department during inpatient boarding.

BACKGROUND

Boarding in the emergency department is an increasingly common phenomenon worldwide. Emergency department staff, patients and their families become more stressed as the duration of boarding in the emergency department increases. Yet, there is limited knowledge of the experiences and concerns of boarded patients.

DESIGN

The qualitative approach of phenomenography was used in the study.

METHODS

The phenomenographic study was conducted in one emergency department that treats approximately 15,000 patients each month. Twenty emergency department boarding patients were recruited between July-September 2014. Semi-structured interviews were used for data collection. The seven steps of qualitative data analysis for a phenomenographic study - familiarisation, articulation, condensation, grouping, comparison, labelling and contrasting - were employed to develop an understanding of participants' experiences and concerns during their inpatient boarding in the emergency department.

RESULTS

The perceptions that emerged from the data were collected into four categories of description of the phenomenon of emergency department boarding patients: a helpless choice; loyalty to specific hospitals and doctors; an inevitable challenge of life; and distrust of the healthcare system. The outcome space for the emergency department boarding patients was waiting and hoping for a cure.

CONCLUSION

The experiences and concerns of emergency department boarding patients include physical, psychological, spiritual and health system dimensions. It is necessary to develop an integrated model of care for these patients.

RELEVANCE TO CLINICAL PRACTICE

Understanding the experiences and concerns of patients who are placed on boarding status in the ED will help emergency healthcare professionals to improve the quality of emergency care. There is a need to develop a care model and associated intervention measures for emergency department patients during the boarding process. The results of this study will help health regulatory authorities to develop an appropriate emergency department boarding system so that patients receive better emergency care.