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Maltoni M, Scarpi E, Dall’Agata M, Micheletti S, Pallotti MC, Pieri M, Ricci M, Romeo A, Tenti MV, Tontini L, Rossi R. Prognostication in palliative radiotherapy—ProPaRT: Accuracy of prognostic scores. Front Oncol 2022; 12:918414. [PMID: 36052228 PMCID: PMC9425085 DOI: 10.3389/fonc.2022.918414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPrognostication can be used within a tailored decision-making process to achieve a more personalized approach to the care of patients with cancer. This prospective observational study evaluated the accuracy of the Palliative Prognostic score (PaP score) to predict survival in patients identified by oncologists as candidates for palliative radiotherapy (PRT). We also studied interrater variability for the clinical prediction of survival and PaP scores and assessed the accuracy of the Survival Prediction Score (SPS) and TEACHH score.Materials and methodsConsecutive patients were enrolled at first access to our Radiotherapy and Palliative Care Outpatient Clinic. The discriminating ability of the prognostic models was assessed using Harrell’s C index, and the corresponding 95% confidence intervals (95% CI) were obtained by bootstrapping.ResultsIn total, 255 patients with metastatic cancer were evaluated, and 123 (48.2%) were selected for PRT, all of whom completed treatment without interruption. Then, 10.6% of the irradiated patients who died underwent treatment within the last 30 days of life. The PaP score showed an accuracy of 74.8 (95% CI, 69.5–80.1) for radiation oncologist (RO) and 80.7 (95% CI, 75.9–85.5) for palliative care physician (PCP) in predicting 30-day survival. The accuracy of TEACHH was 76.1 (95% CI, 70.9–81.3) and 64.7 (95% CI, 58.8–70.6) for RO and PCP, respectively, and the accuracy of SPS was 70 (95% CI, 64.4–75.6) and 72.8 (95% CI, 67.3–78.3).ConclusionAccurate prognostication can identify candidates for low-fraction PRT during the last days of life who are more likely to complete the planned treatment without interruption.All the scores showed good discriminating capacity; the PaP had the higher accuracy, especially when used in a multidisciplinary way.
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Affiliation(s)
- Marco Maltoni
- Medical Oncology Unit, Department of Specialized, Experimental and Diagnostic Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Emanuela Scarpi
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
- *Correspondence: Emanuela Scarpi,
| | - Monia Dall’Agata
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Simona Micheletti
- Radiotherapy Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Maria Caterina Pallotti
- Palliative Care Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Martina Pieri
- Radiotherapy Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Marianna Ricci
- Palliative Care Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Antonino Romeo
- Radiotherapy Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | | | - Luca Tontini
- Radiotherapy Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Romina Rossi
- Palliative Care Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
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Live well, die well – an international cohort study on experiences, concerns and preferences of patients in the last phase of life: the research protocol of the iLIVE study. BMJ Open 2022. [PMCID: PMC9362824 DOI: 10.1136/bmjopen-2021-057229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Introduction Adequately addressing the needs of patients at the end of life and their relatives is pivotal in preventing unnecessary suffering and optimising their quality of life. The purpose of the iLIVE study is to contribute to high-quality personalised care at the end of life in different countries and cultures, by investigating the experiences, concerns, preferences and use of care of terminally ill patients and their families. Methods and analysis The iLIVE study is an international cohort study in which patients with an estimated life expectancy of 6 months or less are followed up until they die. In total, 2200 patients will be included in 11 countries, that is, 200 per country. In addition, one relative per patient is invited to participate. All participants will be asked to fill in a questionnaire, at baseline and after 4 weeks. If a patient dies within 6 months of follow-up, the relative will be asked to fill in a post-bereavement questionnaire. Healthcare use in the last week of life will be evaluated as well; healthcare staff who attended the patient will be asked to fill in a brief questionnaire to evaluate the care that was provided. Qualitative interviews will be conducted with patients, relatives and healthcare professionals in all countries to gain more in-depth insights. Ethics and dissemination The cohort study has been approved by ethics committees and the institutional review boards (IRBs) of participating institutes in all countries. Results will be disseminated through the project website, publications in scientific journals and at conferences. Within the project, there will be a working group focusing on enhancing the engagement of the community at large with the reality of death and dying. Trial registration number NCT04271085.
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van Lummel EV, Ietswaard L, Zuithoff NP, Tjan DH, van Delden JJ. The utility of the surprise question: A useful tool for identifying patients nearing the last phase of life? A systematic review and meta-analysis. Palliat Med 2022; 36:1023-1046. [PMID: 35769037 PMCID: PMC10941345 DOI: 10.1177/02692163221099116] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The surprise question is widely used to identify patients nearing the last phase of life. Potential differences in accuracy between timeframe, patient subgroups and type of healthcare professionals answering the surprise question have been suggested. Recent studies might give new insights. AIM To determine the accuracy of the surprise question in predicting death, differentiating by timeframe, patient subgroup and by type of healthcare professional. DESIGN Systematic review and meta-analysis. DATA SOURCES Electronic databases PubMed, Embase, Cochrane Library, Scopus, Web of Science and CINAHL were searched from inception till 22nd January 2021. Studies were eligible if they used the surprise question prospectively and assessed mortality. Sensitivity, specificity, negative predictive value, positive predictive value and c-statistic were calculated. RESULTS Fifty-nine studies met the inclusion criteria, including 88.268 assessments. The meta-analysis resulted in an estimated sensitivity of 71.4% (95% CI [66.3-76.4]) and specificity of 74.0% (95% CI [69.3-78.6]). The negative predictive value varied from 98.0% (95% CI [97.7-98.3]) to 88.6% (95% CI [87.1-90.0]) with a mortality rate of 5% and 25% respectively. The positive predictive value varied from 12.6% (95% CI [11.0-14.2]) with a mortality rate of 5% to 47.8% (95% CI [44.2-51.3]) with a mortality rate of 25%. Seven studies provided detailed information on different healthcare professionals answering the surprise question. CONCLUSION We found overall reasonable test characteristics for the surprise question. Additionally, this study showed notable differences in performance within patient subgroups. However, we did not find an indication of notable differences between timeframe and healthcare professionals.
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Affiliation(s)
- Eline Vtj van Lummel
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Larissa Ietswaard
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicolaas Pa Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Dave Ht Tjan
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Johannes Jm van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Mitchell S, Leach I, Turner N, Mayland CR. Understanding patient views and experiences of the IDENTIfication of PALLiative care needs (IDENTI-Pall): a qualitative interview study protocol. BMJ Open 2022; 12:e062500. [PMID: 35697465 PMCID: PMC9196159 DOI: 10.1136/bmjopen-2022-062500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION More people are living with multimorbidity, defined as two or more long-term physical or mental health conditions. Multimorbidity is associated with poor quality of life and high treatment burden. Palliative care identification tools have been developed for use in primary care to seek out patients who could benefit from a palliative approach to their care. There has been little evaluative research on such tools; patient perspectives on the process of identifying their palliative care needs is a significant gap. The aim of this research is to provide new understanding into patient perspectives of the experience of having their palliative care needs identified, and the impact on their healthcare. METHODS AND ANALYSIS This qualitative study will employ semistructured interviews to elicit the views of participants. We will purposively sample 10-12 adults with advanced serious illness who have been identified by their primary care team as having palliative care needs, and/or are receiving care from specialist palliative care services. A family member or carer may be included in an interview at the participant's request. A descriptive, thematic analysis will be carried out using the data analysis software NVivo. ETHICS AND DISSEMINATION Ethical approval has been granted by the North of Scotland Research Ethics Committee. Study findings will be disseminated in peer-reviewed journals and through conference presentations. Other activities include the development of patient-centred outcomes for clinical practice and policy in relation to the use of palliative care identification tools. TRIAL REGISTRATION NUMBER National Institute for Health Research (NIHR) Clinical Studies Portfolio, UK Clinical Research Network (UKCRN) Study number 51296.
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Affiliation(s)
- Sarah Mitchell
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Isabel Leach
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Nicola Turner
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - C R Mayland
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
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Zachariah FJ, Rossi LA, Roberts LM, Bosserman LD. Prospective Comparison of Medical Oncologists and a Machine Learning Model to Predict 3-Month Mortality in Patients With Metastatic Solid Tumors. JAMA Netw Open 2022; 5:e2214514. [PMID: 35639380 PMCID: PMC9157269 DOI: 10.1001/jamanetworkopen.2022.14514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/24/2022] [Indexed: 12/29/2022] Open
Abstract
Importance To date, oncologist and model prognostic performance have been assessed independently and mostly retrospectively; however, how model prognostic performance compares with oncologist prognostic performance prospectively remains unknown. Objective To compare oncologist performance with a model in predicting 3-month mortality for patients with metastatic solid tumors in an outpatient setting. Design, Setting, and Participants This prognostic study evaluated prospective predictions for a cohort of patients with metastatic solid tumors seen in outpatient oncology clinics at a National Cancer Institute-designated cancer center and associated satellites between December 6, 2019, and August 6, 2021. Oncologists (57 physicians and 17 advanced practice clinicians) answered a 3-month surprise question (3MSQ) within clinical pathways. A model was trained with electronic health record data from January 1, 2013, to April 24, 2019, to identify patients at high risk of 3-month mortality and deployed silently in October 2019. Analysis was limited to oncologist prognostications with a model prediction within the preceding 30 days. Exposures Three-month surprise question and gradient-boosting binary classifier. Main Outcomes and Measures The primary outcome was performance comparison between oncologists and the model to predict 3-month mortality. The primary performance metric was the positive predictive value (PPV) at the sensitivity achieved by the medical oncologists with their 3MSQ answers. Results A total of 74 oncologists answered 3099 3MSQs for 2041 patients with advanced cancer (median age, 62.6 [range, 18-96] years; 1271 women [62.3%]). In this cohort with a 15% prevalence of 3-month mortality and 30% sensitivity for both oncologists and the model, the PPV of oncologists was 34.8% (95% CI, 30.1%-39.5%) and the PPV of the model was 60.0% (95% CI, 53.6%-66.3%). Area under the receiver operating characteristic curve for the model was 81.2% (95% CI, 79.1%-83.3%). The model significantly outperformed the oncologists in short-term mortality. Conclusions and Relevance In this prognostic study, the model outperformed oncologists overall and within the breast and gastrointestinal cancer cohorts in predicting 3-month mortality for patients with advanced cancer. These findings suggest that further studies may be useful to examine how model predictions could improve oncologists' prognostic confidence and patient-centered goal-concordant care at the end of life.
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Affiliation(s)
- Finly J. Zachariah
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California
| | - Lorenzo A. Rossi
- Department of Applied AI and Data Science, City of Hope National Medical Center, Duarte, California
| | - Laura M. Roberts
- Department of Clinical Informatics, City of Hope National Medical Center, Duarte, California
| | - Linda D. Bosserman
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, California
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Owusuaa C, van der Leest C, Helfrich G, Heller-Baan R, van Loenhout CJ, Herbrink JW, Nieboer D, van der Rijt CCD, van der Heide A. The development of the ADO-SQ model to predict 1-year mortality in patients with COPD. Palliat Med 2022; 36:821-829. [PMID: 35331047 PMCID: PMC9087317 DOI: 10.1177/02692163221080662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Goals of end-of-life care must be adapted to the needs of patients with chronic obstructive pulmonary disease (COPD) who are in the last phase of life. However, identification of those patients is limited by moderate performances of existing prognostic models and by limited validation of the often-recommended surprise question. AIM To develop a clinical prediction model to predict 1-year mortality in patients with COPD. DESIGN Prospective study using logistic regression to develop a model in two steps: (1) external validation of the ADO, BODEX, or CODEX models (A = age; B = body mass index; C = comorbidity; D = dyspnea; EX = exacerbations; O = airflow obstruction); (2) updating of best performing model and extending it with the surprise question. Discriminative performance of the new model was assessed using internal-external validation and measured with area under the curve (AUC). A nomogram and web application were developed. SETTINGS/PARTICIPANTS Patients with COPD from five hospitals (September-November 2017). RESULTS Of the 358 included patients (median age 69.5 years, 50% male), 63 (17%) died within a year. The ADO index (AUC 0.73) had the best discriminative ability compared to the BODEX (AUC 0.71) or CODEX (AUC 0.68), and was extended with the surprise question. The resulting ADO-surprise question (SQ) model had an AUC of 0.79. CONCLUSION The ADO-SQ model offers improved discriminative performance for predicting 1-year mortality compared to the surprise question, ADO, BODEX, or CODEX. A user-friendly nomogram and web application (https://dnieboer.shinyapps.io/copd) were developed. Further external validation of the ADO-SQ in patient groups is needed.
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Affiliation(s)
- Catherine Owusuaa
- Department of Medical Oncology, Erasmus
MC Cancer Institute, Rotterdam, The Netherlands
| | - Cor van der Leest
- Department of Pulmonary Diseases,
Amphia Hospital, Breda, The Netherlands
| | - Gea Helfrich
- Department of Pulmonary Diseases,
Maasstad Hospital, Rotterdam, The Netherlands
| | - Roxane Heller-Baan
- Department of Pulmonary Diseases,
Ikazia Hospital, Rotterdam, The Netherlands
| | - CJ van Loenhout
- Department of Pulmonary Diseases,
Admiraal De Ruyter Hospital, Goes, The Netherlands
| | - Jacobine W Herbrink
- Department of Pulmonary Diseases, Van
Weel Bethesda Hospital, Dirksland, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus
MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Carin CD van der Rijt
- Department of Medical Oncology, Erasmus
MC Cancer Institute, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus
MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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Waller A, Hobden B, Fakes K, Clark K. A Systematic Review of the Development and Implementation of Needs-Based Palliative Care Tools in Heart Failure and Chronic Respiratory Disease. Front Cardiovasc Med 2022; 9:878428. [PMID: 35498028 PMCID: PMC9043454 DOI: 10.3389/fcvm.2022.878428] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/25/2022] [Indexed: 11/19/2022] Open
Abstract
Background The impetus to develop and implement tools for non-malignant patient groups is reflected in the increasing number of instruments being developed for heart failure and chronic respiratory diseases. Evidence syntheses of psychometric quality and clinical utility of these tools is required to inform research and clinical practice. Aims This systematic review examined palliative care needs tools for people diagnosed with advanced heart failure or chronic respiratory diseases, to determine their: (1) psychometric quality; and (2) acceptability, feasibility and clinical utility when implemented in clinical practice. Methods Systematic searches of MEDLINE, CINAHL, Embase, Cochrane and PsycINFO from database inception until June 2021 were undertaken. Additionally, the reference lists of included studies were searched for relevant articles. Psychometric properties of identified measures were evaluated against pre-determined and standard criteria. Results Eighteen tools met inclusion criteria: 11 were developed to assess unmet patient palliative care needs. Of those, 6 were generic, 4 were developed for heart failure and 1 was developed for interstitial lung disease. Seven tools identified those who may benefit from palliative care and include general and disease-specific indicators. The psychometric qualities of the tools varied. None met all of the accepted criteria for psychometric rigor in heart failure or respiratory disease populations. There is limited implementation of needs assessment tools in practice. Conclusion Several tools were identified, however further validation studies in heart failure and respiratory disease populations are required. Rigorous evaluation to determine the impact of adopting a systematic needs-based approach for heart failure and lung disease on the physical and psychosocial outcomes of patients and carers, as well as the economic costs and benefits to the healthcare system, is required.
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Affiliation(s)
- Amy Waller
- Health Behaviour Research Collaborative, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- *Correspondence: Amy Waller
| | - Breanne Hobden
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Kristy Fakes
- Health Behaviour Research Collaborative, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Katherine Clark
- Northern Sydney Local Health District (NSLHD) Supportive and Palliative Care Network, St Leonards, NSW, Australia
- Northern Clinical School, The University of Sydney, Darlington, NSW, Australia
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
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Mulligan L, Sommerfeldt AC, Henderson L, Butcherine K, Chong YH. Introducing and Implementing a Universally Accepted, Readily Accessible, and Actionable End-of-Life Planning Tool for Patients with Advanced Serious Illness or Frailty in Southern New Zealand. J Palliat Med 2022; 25:1484-1491. [PMID: 35384738 DOI: 10.1089/jpm.2021.0638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Each health provider/agency in Southland, New Zealand, previously had its own forms and processes to document and communicate the planned scope of treatment; this project attempted to consolidate and streamline these variable processes into one actionable medical order that is valid in all settings. Aim: The hypothesis was that the intervention would reduce unnecessary hospitalizations in the final year of life. Design: The Clinical Order Articulating Scope of Treatment (COAST) form was a single-page medical order designed to document and communicate the resuscitation status and scope of medical treatment for adult patients believed to be in the final year of life, as evidenced by a "no" response to the Surprise Question. This three-phase initiative piloted the use of the COAST form in Southland from May 2019 to January 2020. Results: One hundred eighty-three patients with COAST forms consented to study participation. Sixty-one percent had a malignant primary diagnosis. The average number of emergency department (ED) presentations in the 12 months before COAST form implementation was 1.5 per person, and the average number of hospital admissions per person was 2.2. This was reduced to 0.5 and 0.5, respectively, in the 12 months following COAST implementation (p = 0.00). Three patients had no ED presentations/hospital admissions in the 12 months before COAST implementation, compared with 29 following COAST implementation, and 66.7% of patients died between May 2019 and February 2021. Conclusions: Patients with a COAST form had significantly fewer ED presentations and hospital admissions in the 12 months following implementation.
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Affiliation(s)
- Laura Mulligan
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
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Owusuaa C, Dijkland SA, Nieboer D, van der Rijt CCD, van der Heide A. Predictors of mortality in chronic obstructive pulmonary disease: a systematic review and meta-analysis. BMC Pulm Med 2022; 22:125. [PMID: 35379214 PMCID: PMC8978392 DOI: 10.1186/s12890-022-01911-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background Better insight in patients’ prognosis can help physicians to timely initiate advance care planning (ACP) discussions with patients with chronic obstructive pulmonary disease (COPD). We aimed to identify predictors of mortality. Methods We systematically searched databases Embase, PubMed, MEDLINE, Web of Science, and Cochrane Central in April 2020. Papers reporting on predictors or prognostic models for mortality at 3 months and up to 24 months were assessed on risk-of-bias. We performed a meta-analysis with a fixed or random-effects model, and evaluated the discriminative ability of multivariable prognostic models. Results We included 42 studies (49–418,251 patients); 18 studies were included in the meta-analysis. Significant predictors of mortality within 3–24 months in the random-effects model were: previous hospitalization for acute exacerbation (hazard ratio [HR] 1.97; 95% confidence interval [CI] 1.32–2.95), hospital readmission within 30 days (HR 5.01; 95% CI 2.16–11.63), cardiovascular comorbidity (HR 1.89; 95% CI 1.25–2.87), age (HR 1.48; 95% CI 1.38–1.59), male sex (HR 1.68; 95% CI 1.38–1.59), and long-term oxygen therapy (HR 1.74; 95% CI 1.10–2.73). Nineteen previously developed multicomponent prognostic models, as examined in 11 studies, mostly had moderate discriminate ability. Conclusion Identified predictors of mortality may aid physicians in selecting COPD patients who may benefit from ACP. However, better discriminative ability of prognostic models or development of a new prognostic model is needed for further large-scale implementation. Registration: PROSPERO (CRD42016038494), https://www.crd.york.ac.uk/prospero/. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01911-5.
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Affiliation(s)
- Catherine Owusuaa
- Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Simone A Dijkland
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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Maes H, Van Den Noortgate N, De Brauwer I, Velghe A, Desmedt M, De Saint-Hubert M, Piers R. Prognostic value of the Surprise Question for one-year mortality in older patients: a prospective multicenter study in acute geriatric and cardiology units. Acta Clin Belg 2022; 77:286-294. [PMID: 33044915 DOI: 10.1080/17843286.2020.1829869] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine the prognostic value of the Surprise Question (SQ) in older persons. METHODS A multicenter prospective study, including patients aged 75 years or older admitted to acute geriatric (AGU) or cardiology unit (CU). The SQ was answered by the treating physician. Patients or relatives were contacted after 1 year to determine 1-year survival. Logistic regression was used to explore parameters associated with SQ. Summary ROC curves were constructed to obtain the pooled values of sensitivity and specificity based on a bivariate model. RESULTS The SQ was positive (death within 1 year is no surprise) in 34.7% AGU and 33.3% CU patients (p = 0.773). Parameters associated with a positive SQ were more severe comorbidity, worse functionality, significant weight loss, refractory symptoms and the request for palliative care by patient or family. One-year mortality was, respectively, 24.9% and 20.2% for patients hospitalized on AGU and CU (p = 0.319). There was no difference in sensitivity or specificity, respectively, 64% and 77% (AUC 0.635) for AGU versus 63% and 76% (AUC 0.758) for CU (p = 0.870). A positive SQ is associated with a significant shorter time until death (HR 5.425 (95% CI 3.332-8.834), p < 0.001) independently from the ward. CONCLUSION The Surprise Question is moderately accurate to predict 1-year mortality in older persons hospitalized on acute geriatric and cardiologic units.
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Affiliation(s)
- Hanne Maes
- Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Isabelle De Brauwer
- Geriatric Medicine, Saint Luc UCLouvain, Bruxelles, Belgium
- Geriatric Medicine, CHU-UCL Namur, Belgium
| | - Anja Velghe
- Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | | | | | - Ruth Piers
- Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
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Patient Identification for Serious Illness Conversations: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074162. [PMID: 35409844 PMCID: PMC8998898 DOI: 10.3390/ijerph19074162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 02/04/2023]
Abstract
Serious illness conversations aim to align medical care and treatment with patients’ values, goals, priorities, and preferences. Timely and accurate identification of patients for serious illness conversations is essential; however, existent methods for patient identification in different settings and population groups have not been compared and contrasted. This study aimed to examine the current literature regarding patient identification for serious illness conversations within the context of the Serious Illness Care Program and/or the Serious Illness Conversation Guide. A scoping review was conducted using the Joanna Briggs Institute guidelines. A comprehensive search was undertaken in four databases for literature published between January 2014 and September 2021. In total, 39 articles met the criteria for inclusion. This review found that patients were primarily identified for serious illness conversations using clinical/diagnostic triggers, the ’surprise question’, or a combination of methods. A diverse assortment of clinicians and non-clinical resources were described in the identification process, including physicians, nurses, allied health staff, administrative staff, and automated algorithms. Facilitators and barriers to patient identification are elucidated. Future research should test the efficacy of adapted identification methods and explore how clinicians inform judgements surrounding patient identification.
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Mori M, Morita T, Bruera E, Hui D. Prognostication of the last days of life: Review article. Cancer Res Treat 2022; 54:631-643. [PMID: 35381165 PMCID: PMC9296934 DOI: 10.4143/crt.2021.1573] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 03/26/2022] [Indexed: 12/01/2022] Open
Abstract
Accurate prediction of impending death (i.e., last few days of life) is essential for terminally-ill cancer patients and their families. International guidelines state that clinicians should identify patients with impending death, communicate the prognosis with patients and families, help them with their end-of-life decision-making, and provide sufficient symptom palliation. Over the past decade, several national and international studies have been conducted that systematically investigated signs and symptoms of impending death as well as how to communicate such a prognosis effectively with patients and families. In this article, we summarize the current evidence on prognostication and communication regarding the last days of life of patients with cancer, and future directions of clinical research.
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Comparison of intuitive assessment and palliative care screening tool in the early identification of patients needing palliative care. Sci Rep 2022; 12:4955. [PMID: 35322098 PMCID: PMC8943025 DOI: 10.1038/s41598-022-08886-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/30/2021] [Indexed: 12/02/2022] Open
Abstract
The intuitive assessment of palliative care (PC) needs and Palliative Care Screening Tool (PCST) are the assessment tools used in the early detection of patients requiring PC. However, the comparison of their prognostic accuracies has not been extensively studied. This cohort study aimed to compare the validity of intuitive assessment and PCST in terms of recognizing patients nearing end-of-life (EOL) and those appropriate for PC. All adult patients admitted to Taipei City Hospital from 2016 through 2019 were included in this prospective study. We used both the intuitive assessment of PC and PCST to predict patients’ 6-month mortality and identified those appropriate for PC. The c-statistic value was calculated to indicate the predictive accuracies of the intuition and PCST. Of 111,483 patients, 4.5% needed PC by the healthcare workers’ intuitive assessment, and 6.7% had a PCST score ≥ 4. After controlling for other covariates, a positive response ‘yes’ to intuitive assessment of PC needs [adjusted odds ratio (AOR) = 9.89; 95% confidence interval (CI) 914–10.71] and a PCST score ≥ 4 (AOR = 6.59; 95%CI 6.17–7.00) were the independent predictors of 6-month mortality. Kappa statistics showed moderate concordance between intuitive assessment and PCST in predicting patients' 6-month mortality (k = 0.49). The c-statistic values of the PCST at recognizing patients’ 6-month mortality was significantly higher than intuition (0.723 vs. 0.679; p < 0.001). As early identification of patients in need of PC could improve the quality of EOL care, our results suggest that it is imperative to screen patients’ palliative needs by using a highly accurate screening tool of PCST.
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Fessele KL, Davis ME, Lasa-Blandon MS, Reidy ME, Barton-Burke M. Perceived End-of-Life Educational Needs by Clinical Trials Nurses at a Comprehensive Cancer Center. Asia Pac J Oncol Nurs 2022; 9:100052. [PMID: 35651541 PMCID: PMC9149015 DOI: 10.1016/j.apjon.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/03/2022] [Indexed: 11/04/2022] Open
Abstract
Objective Determine palliative care end-of-life (EOL) educational needs among clinical trials nurses (CTNs) at an urban comprehensive cancer center. Methods The End-Of-Life Professional Caregiver Survey (EPCS) was used to determine the EOL educational needs of CTNs and collect demographics on years of experience, education, past EOL-specific training, and possession of their own advanced directive. The “Surprise Question” was also asked to explore the percent of patients on clinical trials who may be nearing EOL. Results Twenty-nine CTNs completed the survey. Mean years of experience as an RN and CTN was 10.45 and 2.5, respectively. 79% and 17% held a bachelors or master's degree, respectively. Twenty-seven percent reported previous End-of-Life Nursing Education Consortium (ELNEC) or similar training and 20% stated they had their own advanced directive. Mean total score for the EPCS was 94.83, with subscale means of 42.41 for the Patient and Family Centered Communication (PFCC), 26.9 for Cultural and Ethical Values (CEV), and 25.52 for the Effective Care Delivery (ECD). Highest scoring items included confidence in communicating with colleagues about EOL care, being present with dying patients, and recognizing patients who are appropriate for hospice referral. Lowest scoring items included participating in code status discussions, resolving ethical issues and family conflicts at EOL, and addressing requests for assisted suicide. Responses to the Surprise Question indicated that 27.5% of the CTNs would not be surprised if half or more of their patients died within the next 12 months. Conclusions Many patients with cancer on clinical trials may be nearing EOL. CTNs perceive the need for education to increase confidence in handling difficult communication.
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Yeoh LY, Seow YY, Tan HC. Identifying high-risk hospitalised chronic kidney disease patient using electronic health records for serious illness conversation. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:161-169. [PMID: 35373239 DOI: 10.47102/annals-acadmedsg.2021427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION This study aimed to identify risk factors that are associated with increased mortality that could prompt a serious illness conversation (SIC) among patients with chronic kidney disease (CKD). METHODS The electronic health records of adult CKD patients admitted between August 2018 and February 2020 were retrospectively reviewed to identify CKD patients with >1 hospitalisation and length of hospital stay ≥4 days. Outcome measures were mortality and the duration of hospitalisation. We also assessed the utility of the Cohen's model to predict 6-month mortality among CKD patients. RESULTS A total of 442 patients (mean age 68.6 years) with median follow-up of 15.3 months were identified. The mean (standard deviation) Charlson Comorbidity Index [CCI] was 6.8±2.0 with 48.4% on chronic dialysis. The overall mortality rate until August 2020 was 36.7%. Mortality was associated with age (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.29-1.77), CCI≥7 (1.58, 1.08-2.30), lower serum albumin (1.09, 1.06-1.11), readmission within 30-day (1.96, 1.43-2.68) and CKD non-dialysis (1.52, 1.04-2.17). Subgroup analysis of the patients within first 6-month from index admission revealed longer hospitalisation stay for those who died (CKD-non dialysis: 5.5; CKD-dialysis: 8.0 versus 4 days for those survived, P<0.001). The Cohen's model demonstrated reasonable predictive ability to discriminate 6-month mortality (area under the curve 0.81, 95% CI 0.75-0.87). Only 24 (5.4%) CKD patients completed advanced care planning. CONCLUSION CCI, serum albumin and recent hospital readmission could identify CKD patients at higher risk of mortality who could benefit from a serious illness conversation.
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Affiliation(s)
- Lee Ying Yeoh
- Department of General Medicine, Sengkang General Hospital, Singapore
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End of life care pathways in the Emergency Department and their effects on patient and health service outcomes: An integrative review. Int Emerg Nurs 2022; 61:101153. [PMID: 35240435 DOI: 10.1016/j.ienj.2022.101153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/07/2022] [Accepted: 01/31/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION End of life (EOL) care in the Emergency Department (ED) requires focused, person-centred care to meet the needs of this vulnerable cohort of patients. METHODS An integrative review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was conducted. Studies were included if they were primary research relating to patients in the ED at the EOL, and/or evaluated EOL care pathways in the ED. Databases OVID Emcare, OVID Medline, and Scopus were searched from 1966-September 2021; followed by screening and appraisal. Articles were compared and data grouped into categories. RESULTS Eleven research articles were included generating three categories for EOL care in ED. 1) tools/criteria to identify patients who may require EOL care in ED; 2) processes for providing EOL care, and 3) implementation methods/frameworks to support the uptake of EOL care processes. CONCLUSION There were some commonalities in the criteria used to identify patients who may be at their EOL and the interventions implemented thereafter. There was no standardised process for screening for or treating EOL care needs in the ED. Further research is required to determine the impact that EOL care pathways have on patient and health service outcomes to inform strategies for future policy development.
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Gaffney L, Jonsson A, Judge C, Costello M, O’Donnell J, O’Caoimh R. Using the "Surprise Question" to Predict Frailty and Healthcare Outcomes among Older Adults Attending the Emergency Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031709. [PMID: 35162732 PMCID: PMC8834777 DOI: 10.3390/ijerph19031709] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 11/16/2022]
Abstract
The “surprise question” (SQ) predicts the need for palliative care. Its predictive validity for adverse healthcare outcomes and its association with frailty among older people attending the emergency department (ED) are unknown. We conducted a secondary analysis of a prospective study of consecutive patients aged ≥70 attending a university hospital’s ED. The SQ was scored by doctors before an independent comprehensive geriatric assessment (CGA). Outcomes included length of stay (LOS), frailty determined by CGA and one-year mortality. The SQ was available for 191 patients, whose median age was 79 ± 9. In all, 56/191 (29%) screened SQ positive. SQ positive patients were frailer; the median clinical frailty score was 6/9 (compared to 4/9, p < 0.001); they had longer LOS (p = 0.008); and they had higher mortality (p < 0.001). Being SQ positive was associated with 2.6 times greater odds of admission and 8.9 times odds of frailty. After adjustment for age, sex, frailty, co-morbidity and presenting complaint, patients who were SQ positive had significantly reduced survival times (hazard ratio 5.6; 95% CI: 1.39–22.3, p = 0.015). Almost one-third of older patients attending ED were identified as SQ positive. These were frailer and more likely to be admitted, have reduced survival times and have prolonged LOS. The SQ is useful to quickly stratify older patients likely to experience poor outcomes in ED.
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Affiliation(s)
- Laura Gaffney
- Department of Geriatric and Stroke Medicine, University Hospital Galway, Newcastle Rd, H91 YR71 Galway, Ireland; (L.G.); (C.J.); (M.C.)
- Department of Palliative Care Medicine, University Hospital Galway, Newcastle Rd, H91 YR71 Galway, Ireland
| | - Agnes Jonsson
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland;
| | - Conor Judge
- Department of Geriatric and Stroke Medicine, University Hospital Galway, Newcastle Rd, H91 YR71 Galway, Ireland; (L.G.); (C.J.); (M.C.)
- Department of Palliative Care Medicine, University Hospital Galway, Newcastle Rd, H91 YR71 Galway, Ireland
| | - Maria Costello
- Department of Geriatric and Stroke Medicine, University Hospital Galway, Newcastle Rd, H91 YR71 Galway, Ireland; (L.G.); (C.J.); (M.C.)
- Department of Palliative Care Medicine, University Hospital Galway, Newcastle Rd, H91 YR71 Galway, Ireland
| | - John O’Donnell
- Department of Emergency Medicine, University Hospital Galway, Newcastle Rd, H91 YR71 Galway, Ireland;
| | - Rónán O’Caoimh
- Department of Geriatric and Stroke Medicine, University Hospital Galway, Newcastle Rd, H91 YR71 Galway, Ireland; (L.G.); (C.J.); (M.C.)
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, T12 WE28 Cork, Ireland;
- Correspondence: or
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Theunissen M, Magdelijns FJ, Janssen DJ, Naaktgeboren MW, Courtens A, van Kuijk SM, van den Beuken-van Everdingen M. The Surprise Question in Older Hospitalized Patients: To Use or Not to Use? J Am Med Dir Assoc 2022; 23:894-896.e1. [DOI: 10.1016/j.jamda.2022.01.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/07/2022] [Accepted: 01/13/2022] [Indexed: 01/23/2023]
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Owusuaa C, Dijkland SA, Nieboer D, van der Heide A, van der Rijt CCD. Predictors of Mortality in Patients with Advanced Cancer-A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:328. [PMID: 35053493 PMCID: PMC8774229 DOI: 10.3390/cancers14020328] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/31/2021] [Accepted: 01/07/2022] [Indexed: 02/01/2023] Open
Abstract
To timely initiate advance care planning in patients with advanced cancer, physicians should identify patients with limited life expectancy. We aimed to identify predictors of mortality. To identify the relevant literature, we searched Embase, MEDLINE, Cochrane Central, Web of Science, and PubMed databases between January 2000-April 2020. Identified studies were assessed on risk-of-bias with a modified QUIPS tool. The main outcomes were predictors and prediction models of mortality within a period of 3-24 months. We included predictors that were studied in ≥2 cancer types in a meta-analysis using a fixed or random-effects model and summarized the discriminative ability of models. We included 68 studies (ranging from 42 to 66,112 patients), of which 24 were low risk-of-bias, and 39 were included in the meta-analysis. Using a fixed-effects model, the predictors of mortality were: the surprise question, performance status, cognitive impairment, (sub)cutaneous metastases, body mass index, comorbidity, serum albumin, and hemoglobin. Using a random-effects model, predictors were: disease stage IV (hazard ratio [HR] 7.58; 95% confidence interval [CI] 4.00-14.36), lung cancer (HR 2.51; 95% CI 1.24-5.06), ECOG performance status 1+ (HR 2.03; 95% CI 1.44-2.86) and 2+ (HR 4.06; 95% CI 2.36-6.98), age (HR 1.20; 95% CI 1.05-1.38), male sex (HR 1.24; 95% CI 1.14-1.36), and Charlson comorbidity score 3+ (HR 1.60; 95% CI 1.11-2.32). Thirteen studies reported on prediction models consisting of different sets of predictors with mostly moderate discriminative ability. To conclude, we identified reasonably accurate non-tumor specific predictors of mortality. Those predictors could guide in developing a more accurate prediction model and in selecting patients for advance care planning.
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Affiliation(s)
- Catherine Owusuaa
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands;
| | - Simone A. Dijkland
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands; (S.A.D.); (D.N.); (A.v.d.H.)
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands; (S.A.D.); (D.N.); (A.v.d.H.)
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands; (S.A.D.); (D.N.); (A.v.d.H.)
| | - Carin C. D. van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands;
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Bowers B, Pollock K, Barclay S. Unwelcome memento mori or best clinical practice? Community end of life anticipatory medication prescribing practice: A mixed methods observational study. Palliat Med 2022; 36:95-104. [PMID: 34493122 PMCID: PMC8796157 DOI: 10.1177/02692163211043382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anticipatory medications are injectable drugs prescribed ahead of possible need for administration if distressing symptoms arise in the final days of life. Little is known about how they are prescribed in primary care. AIM To investigate the frequency, timing and recorded circumstances of anticipatory medications prescribing for patients living at home and in residential care. DESIGN Retrospective mixed methods observational study using General Practitioner and community nursing clinical records. SETTING/PARTICIPANTS 329 deceased adult patients registered with Eleven General Practitioner practices and two associated community nursing services in two English counties (30 most recent deaths per practice). Patients died from any cause except trauma, sudden death or suicide, between 4 March 2017 and 25 September 2019. RESULTS Anticipatory medications were prescribed for 167/329 (50.8%) of the deceased patients, between 0 and 1212 days before death (median 17 days). The likelihood of prescribing was significantly higher for patients with a recorded preferred place of death (odds ratio [OR] 34; 95% CI 15-77; p < 0.001) and specialist palliative care involvement (OR 7; 95% CI 3-19; p < 0.001). For 66.5% of patients (111/167) anticipatory medications were recorded as being prescribed as part of a single end-of-life planning intervention. CONCLUSION The variability in the timing of prescriptions highlights the challenges in diagnosing the end-of-life phase and the potential risks of prescribing far in advance of possible need. Patient and family views and experiences of anticipatory medication care, and their preferences for involvement in prescribing decision-making, warrant urgent investigation.
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Affiliation(s)
- Ben Bowers
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Kristian Pollock
- Nottingham Centre for the Advancement of Research into Supportive, Palliative and End of Life Care, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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White N, Oostendorp LJ, Vickerstaff V, Gerlach C, Engels Y, Maessen M, Tomlinson C, Wens J, Leysen B, Biasco G, Zambrano S, Eychmüller S, Avgerinou C, Chattat R, Ottoboni G, Veldhoven C, Stone P. An online international comparison of palliative care identification in primary care using the Surprise Question. Palliat Med 2022; 36:142-151. [PMID: 34596445 PMCID: PMC8796152 DOI: 10.1177/02692163211048340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Surprise Question ('Would I be surprised if this patient died within 12 months?') identifies patients in the last year of life. It is unclear if 'surprised' means the same for each clinician, and whether their responses are internally consistent. AIM To determine the consistency with which the Surprise Question is used. DESIGN A cross-sectional online study of participants located in Belgium, Germany, Italy, The Netherlands, Switzerland and UK. Participants completed 20 hypothetical patient summaries ('vignettes'). Primary outcome measure: continuous estimate of probability of death within 12 months (0% [certain survival]-100% [certain death]). A threshold (probability estimate above which Surprise Question responses were consistently 'no') and an inconsistency range (range of probability estimates where respondents vacillated between responses) were calculated. Univariable and multivariable linear regression explored differences in consistency. Trial registration: NCT03697213. SETTING/PARTICIPANTS Registered General Practitioners (GPs). Of the 307 GPs who started the study, 250 completed 15 or more vignettes. RESULTS Participants had a consistency threshold of 49.8% (SD 22.7) and inconsistency range of 17% (SD 22.4). Italy had a significantly higher threshold than other countries (p = 0.002). There was also a difference in threshold levels depending on age of clinician, for every yearly increase, participants had a higher threshold. There was no difference in inconsistency between countries (p = 0.53). CONCLUSIONS There is variation between clinicians regarding the use of the Surprise Question. Over half of GPs were not internally consistent in their responses to the Surprise Question. Future research with standardised terms and real patients is warranted.
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Affiliation(s)
- Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Linda Jm Oostendorp
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Primary Care and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Christina Gerlach
- Palliative Care Unit, Department of Oncology, Hematology and BMT, and Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Interdisciplinary Palliative Care Unit, Department of Hematology, Oncology, and Pneumology, University Medical Center, Mainz, Germany
| | - Yvonne Engels
- Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Maud Maessen
- University Center for Palliative Care, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Christopher Tomlinson
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Johan Wens
- Department Family Medicine and Population Health (FamPop), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Bert Leysen
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Guido Biasco
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna & Academy of the Sciences of Palliative Medicine, Bologna, Italy
| | - Sofia Zambrano
- University Center for Palliative Care, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Steffen Eychmüller
- University Center for Palliative Care, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Christina Avgerinou
- Primary Care and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Rabih Chattat
- Department of Psychology, University of Bologna, Bologna, Italy
| | | | - Carel Veldhoven
- Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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Sopcheck J, Tappen RM. Communicating With Nursing Home Residents About End of Life. Am J Hosp Palliat Care 2021; 39:1257-1265. [PMID: 34967673 DOI: 10.1177/10499091211064835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Approximately 33% of the 1.2 million older individuals residing in nursing homes have the capacity to discuss their preferences for end-of-life care, and 35% will die within their first year in the nursing home. These conversations necessary to promote care consistent with the resident's preferences are often limited and most often occur when the resident is actively dying. The purpose of this secondary analysis was to understand the resident's perspectives on end-of-life communication in the nursing home and suggest approaches to facilitate this communication. We interviewed 46 participants (16 residents, 10 family members, and 20 staff) in a Southeast Florida nursing home from January to May 2019. The data were analyzed using descriptive and pattern coding and matrices to decipher preliminary categories and thematic interpretation within and across each participant group. Two themes emerged from this secondary analysis that residents assume others know their end-of-life preferences, and past experiences may predict future end-of-life choices. Residents and family members were willing to discuss end-of-life care. Study findings also suggested that past experiences with the end-of-life and critical illness of another could impact residents' and family members' end-of-life care decisions, and that nurses' recognition of subtle signs of a resident's decline may trigger provider-initiated end-of-life conversations. Future research should focus on strategies to promote earlier end-of-life discussions to support independent decision-making about end-of-life care in this relatively dependent population of older adults.
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Affiliation(s)
| | - Ruth M Tappen
- 1782Florida Atlantic University, Boca Raton, FL, USA
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Petrova M, Wong G, Kuhn I, Wellwood I, Barclay S. Timely community palliative and end-of-life care: a realist synthesis. BMJ Support Palliat Care 2021:bmjspcare-2021-003066. [PMID: 34887313 DOI: 10.1136/bmjspcare-2021-003066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 09/19/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Community-based and home-based palliative and end-of-life care (PEoLC) services, often underpinned by primary care provision, are becoming increasingly popular. One of the key challenges associated with them is their timely initiation. The latter requires an accurate enough prediction of how close to death a patient is. METHODS Using 'realist synthesis' tools, this review sought to develop explanations of how primary care and community PEoLC programmes generate their outcomes, with the explanations presented as context-mechanism-outcome configurations. Medline, Embase, CINAHL, PsycINFO, Web of Science, ASSIA, Sociological Abstracts and SCIE Social Care Online were originally searched. A multistage process of focusing the review was employed, with timely identification of the EoL stage and timely initiation of associated services representing the final review focus. Synthesised sources included 21 full-text documents and 324 coded abstracts, with 253 'core contents' abstracts generating >800 codes. RESULTS Numerous PEoLC policies and programmes are embedded in a framework of Preparation and Planning for Death and Dying, with identification of the dying stage setting in motion key systems and services. This is challenged by: (1) accumulated evidence demonstrating low accuracy of prognostic judgements; (2) many individuals' orientation towards Living and Hope; (3) expanding grey zones between palliative and curative care; (4) the complexity of referral decisions; (5) the loss of pertinent information in hierarchical relationships and (6) the ambiguous value of having 'more time'. CONCLUSION Prioritising temporal criteria in initiating PEoLC services is not sufficiently supported by current evidence and can have significant unintended consequences. PROSPERO REGISTRATION NUMBER CRD42018097218.
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Affiliation(s)
- Mila Petrova
- Palliative & End of Life Care in Cambridge (PELiCAM) Research Group, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Geoff Wong
- Nuffied Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Isla Kuhn
- Medical Library, University of Cambridge, Cambridge, UK
| | - Ian Wellwood
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen Barclay
- Palliative & End of Life Care in Cambridge (PELiCAM) Research Group, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Characteristics of outpatient emergency department visits of nursing home residents: an analysis of discharge letters. Aging Clin Exp Res 2021; 33:3343-3351. [PMID: 33939126 PMCID: PMC8668845 DOI: 10.1007/s40520-021-01863-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/13/2021] [Indexed: 10/30/2022]
Abstract
BACKGROUND Unplanned emergency department (ED) visits of nursing home residents (NHR) are common, with many transfers not leading to hospitalization. However, there is little research on what diagnostic and therapeutic measures are performed during visits. AIMS We analyzed underlying diagnoses, characteristics and performed medical procedures of unplanned outpatient ED visits by NHR. METHODS We conducted a multi-center study of 14 nursing homes (NHs) in northwestern Germany in 03/2018-07/2019. Hospital transfers were documented by nursing staff using a standardized questionnaire for 12 months. In addition, discharge letters were used to collect information about the respective transfer, its reasons and the extend of the medical services performed in the ED. RESULTS A total of 161 unplanned ED visits were included (mean age: 84.2 years; 68.3% females). The main transfer reasons were trauma (59.0%), urinary catheter and nutritional probe problems (overall 10.6%; male NHR 25.5%) and altered mental state (9.9%). 32.9% where discharged without imaging or blood test prior. 67.4% of injured NHR (n = 95) required no or only basic wound care. Catheter-related problems (n = 17) were mainly treated by changing an existing suprapubic catheter (35.3%) and by flushing the pre-existing catheter (29.4%). DISCUSSION Our data suggest that the diagnostic and therapeutic interventions performed in ED, often do not exceed general practitioner (GP) care and many ED visits seem to be unnecessary. CONCLUSION Better coordination and consultation with GPs as well as better training of nursing staff in handling catheter problems could help to reduce the number of ED visits.
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75
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[Palliative Care - more than just Morphines]. MMW Fortschr Med 2021; 163:68-75. [PMID: 34811687 DOI: 10.1007/s15006-021-0284-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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76
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Teike Lüthi F, MacDonald I, Rosselet Amoussou J, Bernard M, Borasio GD, Ramelet AS. Instruments for the identification of patients in need of palliative care in the hospital setting: a systematic review of measurement properties. JBI Evid Synth 2021; 20:761-787. [PMID: 34812189 DOI: 10.11124/jbies-20-00555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review was to provide a comprehensive overview of the measurement properties of the available instruments used by clinicians for identifying adults in need of general or specialized palliative care in hospital settings. INTRODUCTION Identification of patients in need of palliative care has been recognized as an area where many health care professionals need guidance. Differentiating between patients who require general palliative care and patients with more complex conditions who need specialized palliative care is particularly challenging. INCLUSION CRITERIA We included development and validation studies that reported on measurement properties (eg, content validity, reliability, or responsiveness) of instruments used by clinicians for identifying adult patients (>18 years and older) in need of palliative care in hospital settings. METHODS Studies published until March 2020 were searched in four databases: Embase.com, Medline Ovid, PubMed, and CINAHL EBSCO. Unpublished studies were searched in Google Scholar, government websites, hospice websites, the Library Network of Western Switzerland, and WorldCat. The search was not restricted by language; however, only studies published in English or French were eligible for inclusion. The title and abstracts of the studies were screened by two independent reviewers against the inclusion criteria. Full-text studies were reviewed for inclusion by two independent reviewers. The quality of the measurement properties of all included studies were assessed independently by two reviewers according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. RESULTS Out of the 23 instruments identified, four instruments were included, as reported in six studies: the Center to Advance Palliative Care (CAPC) criteria, the Necesidades Paliativas (NECPAL), the Palliative Care Screening Tool (PCST), and the Supportive and Palliative Care Indicators Tool (SPICT). The overall psychometric quality of all four instruments was insufficient according to the COSMIN criteria, with the main deficit being poor construct description during development. CONCLUSIONS For the early identification of patients needing palliative care in hospital settings, there is poor quality and incomplete evidence according to the COSMIN criteria for the four available instruments. This review highlights the need for further development of the construct being measured. This may be done by conducting additional studies on these instruments or by developing a new instrument for the identification of patients in need of palliative care that addresses the current gaps in construct and structural validity. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020150074.
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Affiliation(s)
- Fabienne Teike Lüthi
- Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Switzerland Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Switzerland Psychiatry Library, Education and Research Department, Lausanne University Hospital and University of Lausanne, Site de Cery, Prilly, Switzerland Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST): a Joanna Briggs Institute Centre of Excellence
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Saeed D, Carter G, Parsons C. Interventions to improve medicines optimisation in frail older patients in secondary and acute care settings: a systematic review of randomised controlled trials and non-randomised studies. Int J Clin Pharm 2021; 44:15-26. [PMID: 34800255 PMCID: PMC8866367 DOI: 10.1007/s11096-021-01354-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/09/2021] [Indexed: 12/20/2022]
Abstract
Background: Frailty is a geriatric syndrome in which physiological systems have decreased reserve and resistance against stressors. Frailty is associated with polypharmacy, inappropriate prescribing and unfavourable clinical outcomes. Aim: To identify and evaluate randomised controlled trials (RCTs) and non-randomised studies of interventions designed to optimise the medications of frail older patients, aged 65 years and over, in secondary or acute care settings. Method: Literature searches were conducted across seven electronic databases and three trial registries from the date of inception to October 2021. All types of interventional studies were included. Study selection, data extraction, risk of bias and quality assessment were conducted by two independent reviewers. Results: Three RCTs were eligible for inclusion; two employed deprescribing as the intervention, and one used comprehensive geriatric assessment. All reported significant improvements in prescribing appropriateness. One study investigated the effect of the intervention on clinical outcomes including hospital presentations, falls, fracture, quality of life and mortality, and reported no significant differences in these outcomes, but did report a significant reduction in monthly medication cost. Two of the included studies were assessed as having ‘some concerns’ of bias, and one was judged to be at ‘high risk’ of bias. Conclusion: This systematic review demonstrates that medicines optimisation interventions may improve medication appropriateness in frail older inpatients. However, it highlights the paucity of high-quality evidence that examines the impact of medicines optimisation on quality of prescribing and clinical outcomes for frail older inpatients. High-quality studies are needed to address this gap.
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Affiliation(s)
- Dima Saeed
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Gillian Carter
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Carole Parsons
- School of Pharmacy, Queen's University Belfast, Belfast, UK.
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Cox EGM, Onrust M, Vos ME, Paans W, Dieperink W, Koeze J, van der Horst ICC, Wiersema R. The simple observational critical care studies: estimations by students, nurses, and physicians of in-hospital and 6-month mortality. Crit Care 2021; 25:393. [PMID: 34782000 PMCID: PMC8591867 DOI: 10.1186/s13054-021-03809-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/21/2021] [Indexed: 12/01/2022] Open
Abstract
Background Prognostic assessments of the mortality of critically ill patients are frequently performed in daily clinical practice and provide prognostic guidance in treatment decisions. In contrast to several sophisticated tools, prognostic estimations made by healthcare providers are always available and accessible, are performed daily, and might have an additive value to guide clinical decision-making. The aim of this study was to evaluate the accuracy of students’, nurses’, and physicians’ estimations and the association of their combined estimations with in-hospital mortality and 6-month follow-up. Methods The Simple Observational Critical Care Studies is a prospective observational single-center study in a tertiary teaching hospital in the Netherlands. All patients acutely admitted to the intensive care unit were included. Within 3 h of admission to the intensive care unit, a medical or nursing student, a nurse, and a physician independently predicted in-hospital and 6-month mortality. Logistic regression was used to assess the associations between predictions and the actual outcome; the area under the receiver operating characteristics (AUROC) was calculated to estimate the discriminative accuracy of the students, nurses, and physicians. Results In 827 out of 1,010 patients, in-hospital mortality rates were predicted to be 11%, 15%, and 17% by medical students, nurses, and physicians, respectively. The estimations of students, nurses, and physicians were all associated with in-hospital mortality (OR 5.8, 95% CI [3.7, 9.2], OR 4.7, 95% CI [3.0, 7.3], and OR 7.7 95% CI [4.7, 12.8], respectively). Discriminative accuracy was moderate for all students, nurses, and physicians (between 0.58 and 0.68). When more estimations were of non-survival, the odds of non-survival increased (OR 2.4 95% CI [1.9, 3.1]) per additional estimate, AUROC 0.70 (0.65, 0.76). For 6-month mortality predictions, similar results were observed. Conclusions Based on the initial examination, students, nurses, and physicians can only moderately predict in-hospital and 6-month mortality in critically ill patients. Combined estimations led to more accurate predictions and may serve as an example of the benefit of multidisciplinary clinical care and future research efforts. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03809-w.
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Affiliation(s)
- Eline G M Cox
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Marisa Onrust
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Madelon E Vos
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wolter Paans
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.,Research Group Nursing Diagnostics, Hanze University of Applied Sciences, Groningen, The Netherlands
| | - Willem Dieperink
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.,Research Group Nursing Diagnostics, Hanze University of Applied Sciences, Groningen, The Netherlands
| | - Jacqueline Koeze
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, University Medical Center Maastricht+, University of Maastricht, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.,Department of Cardiology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
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79
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Birgisdóttir D, Duarte A, Dahlman A, Sallerfors B, Rasmussen BH, Fürst CJ. A novel care guide for personalised palliative care - a national initiative for improved quality of care. BMC Palliat Care 2021; 20:176. [PMID: 34763677 PMCID: PMC8582140 DOI: 10.1186/s12904-021-00874-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background Even when palliative care is an integrated part of the healthcare system, the quality is still substandard for many patients and often initiated too late. There is a lack of structured guidelines for identifying and caring for patients; in particular for those with early palliative care needs. A care guide can act as a compass for best practice and support the care of patients throughout their palliative trajectory. Such a guide should both meet the needs of health care professionals and patients and families, facilitating discussion around end-of-life decision-making and enabling them to plan for the remaining time in life. The aim of this article is to describe the development and pilot testing of a novel Swedish palliative care guide. Methods The Swedish Palliative Care Guide (S-PCG) was developed according to the Medical Research Council framework and based on national and international guidelines for good palliative care. An interdisciplinary national advisory committee of over 90 health care professionals together with patient, family and public representatives were engaged in the process. The feasibility was tested in three pilot studies in different care settings. Results After extensive multi-unit and interprofessional testing and evaluation, the S-PCG contains three parts that can be used independently to identify, assess, address, follow up, and document the individual symptoms and care-needs throughout the whole palliative care trajectory. The S-PCG can provide a comprehensive overview and shared understanding of the patients’ needs and possibilities for ensuring optimal quality of life, the family included. Conclusions Based on broad professional cooperation, patients and family participation and clinical testing, the S-PCG provides unique interprofessional guidance for assessment and holistic care of patients with palliative care needs, promotes support to the family, and when properly used supports high-quality personalised palliative care throughout the palliative trajectory. Future steps for the S-PCG, entails scientific evaluation of the clinical impact and effect of S-PCG in different care settings – including implementation, patient and family outcomes, and experiences of patient, family and personnel. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00874-4.
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Affiliation(s)
- Dröfn Birgisdóttir
- Faculty of Medicine, Department of Clinical Sciences Lund, Oncology and Pathology, Institute for Palliative Care, Lund University, Scheeletorget 1, Hus 404B, 223 81, Lund, Sweden. .,The Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden.
| | - Anette Duarte
- The Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden
| | - Anna Dahlman
- Faculty of Medicine, Department of Clinical Sciences Lund, Oncology and Pathology, Institute for Palliative Care, Lund University, Scheeletorget 1, Hus 404B, 223 81, Lund, Sweden
| | - Bengt Sallerfors
- Faculty of Medicine, Department of Clinical Sciences Lund, Oncology and Pathology, Institute for Palliative Care, Lund University, Scheeletorget 1, Hus 404B, 223 81, Lund, Sweden
| | - Birgit H Rasmussen
- The Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden.,Faculty of Medicine, Department for Healthcare Sciences, Institute for Palliative Care, Lund University, Lund, Sweden
| | - Carl Johan Fürst
- Faculty of Medicine, Department of Clinical Sciences Lund, Oncology and Pathology, Institute for Palliative Care, Lund University, Scheeletorget 1, Hus 404B, 223 81, Lund, Sweden.,The Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden
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80
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Eychmüller S, Ramseier F, Zürcher C. [Communicating Prognosis and Expectations in Advanced Disease - A Balancing Act in Practice]. PRAXIS 2021; 110:861-865. [PMID: 34814723 DOI: 10.1024/1661-8157/a003777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Communicating Prognosis and Expectations in Advanced Disease - A Balancing Act in Practice Abstract. To prepare the end of life, to plan important things, to spend the remaining time of life not only with medical treatments, but to live - these are frequently expressed wishes of people with progressive diseases. Prognostic statements are feared by professionals. At the same time, when talking about what lies ahead for those affected, professionals very often make over-optimistic promises. A broader definition of the term prognosis as well as a careful handling of expectations can help to define realistic goals together.
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Affiliation(s)
- Steffen Eychmüller
- Universitäres Zentrum für Palliative Care, Universitätsspital, Inselspital, Bern
| | - Friederike Ramseier
- Universitäres Zentrum für Palliative Care, Universitätsspital, Inselspital, Bern
| | - Claudia Zürcher
- Universitäres Zentrum für Palliative Care, Universitätsspital, Inselspital, Bern
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Lüthi FT, Bernard M, Gamondi C, Ramelet AS, Borasio GD. ID-PALL: An Instrument to Help You Identify Patients in Need of Palliative Care. PRAXIS 2021; 110:839-844. [PMID: 34814722 DOI: 10.1024/1661-8157/a003788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Palliative care is frequently associated with the end of life and cancer. However, other patients may need palliative care, and this need may be present earlier in the disease trajectory. It is therefore essential to identify at the right time patients who need palliative care and to distinguish between those in need of general palliative care and those for whom a referral to specialists is required. ID-PALL has been developed as an instrument to support professionals in this identification and to discuss a suitable palliative care project, in order to maintain the best quality of life for patients and their relatives. Recommendations for clinical practice are also proposed to guide professionals after the identification phase.
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Affiliation(s)
- Fabienne Teike Lüthi
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne
| | - Mathieu Bernard
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne
| | - Claudia Gamondi
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne
- Palliative and Supportive Care Service, Istituto Oncologico della Svizzera Italiana, Bellinzona
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Lausanne
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne
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Todd S, Bernal J, Worth R, Shearn J, Brearley S, McCarron M, Hunt K. Hidden lives and deaths: the last months of life of people with intellectual disabilities living in long-term, generic care settings in the UK. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2021; 34:1489-1498. [PMID: 34031949 DOI: 10.1111/jar.12891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/15/2021] [Accepted: 03/12/2021] [Indexed: 11/27/2022]
Abstract
RATIONALE This paper concerns mortality and needs for end-of-life care in a population of adults with ID living in generic care homes. METHODS Various sampling strategies were used to identify a difficult to find a population of people with ID in generic care homes. Demographic and health data were obtained for 132 people with ID. This included the Surprise Question. At T2, 12 months later, data were obtained on the survival of this sample. FINDINGS The average age was 68.6 years, and the majority were women (55.3%). Their health was typically rated as good or better. Responses to the Surprise Question indicated that 23.3% respondents might need EoLC. At T2, 18.0% of this population had died. The average of death was 72.2 years. The majority died within the care setting (62.9%). IMPLICATIONS The implications for end-of-life care and mortality research are discussed.
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Heyman ET, Ashfaq A, Khoshnood A, Ohlsson M, Ekelund U, Holmqvist LD, Lingman M. Improving Machine Learning 30-Day Mortality Prediction by Discounting Surprising Deaths. J Emerg Med 2021; 61:763-773. [PMID: 34716042 DOI: 10.1016/j.jemermed.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 08/13/2021] [Accepted: 09/11/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Machine learning (ML) is an emerging tool for predicting need of end-of-life discussion and palliative care, by using mortality as a proxy. But deaths, unforeseen by emergency physicians at time of the emergency department (ED) visit, might have a weaker association with the ED visit. OBJECTIVES To develop an ML algorithm that predicts unsurprising deaths within 30 days after ED discharge. METHODS In this retrospective registry study, we included all ED attendances within the Swedish region of Halland in 2015 and 2016. All registered deaths within 30 days after ED discharge were classified as either "surprising" or "unsurprising" by an adjudicating committee with three senior specialists in emergency medicine. ML algorithms were developed for the death subclasses by using Logistic Regression (LR), Random Forest (RF), and Support Vector Machine (SVM). RESULTS Of all 30-day deaths (n = 148), 76% (n = 113) were not surprising to the adjudicating committee. The most common diseases were advanced stage cancer, multidisease/frailty, and dementia. By using LR, RF, and SVM, mean area under the receiver operating characteristic curve (ROC-AUC) of unsurprising deaths in the test set were 0.950 (SD 0.008), 0.944 (SD 0.007), and 0.949 (SD 0.007), respectively. For all mortality, the ROC-AUCs for LR, RF, and SVM were 0.924 (SD 0.012), 0.922 (SD 0.009), and 0.931 (SD 0.008). The difference in prediction performance between all and unsurprising death was statistically significant (P < .001) for all three models. CONCLUSION In patients discharged to home from the ED, three-quarters of all 30-day deaths did not surprise an adjudicating committee with emergency medicine specialists. When only unsurprising deaths were included, ML mortality prediction improved significantly.
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Affiliation(s)
- Ellen Tolestam Heyman
- Department of Emergency Medicine, Halland Hospital, Region Halland, Sweden; Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Awais Ashfaq
- Center for Applied Intelligent Systems Research (CAISR), Halmstad University, Halmstad, Sweden; Halland Hospital, Region Halland, Sweden
| | - Ardavan Khoshnood
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden; Skåne University Hospital Lund, Lund, Sweden
| | - Mattias Ohlsson
- Center for Applied Intelligent Systems Research (CAISR), Halmstad University, Halmstad, Sweden; Department of Astronomy and Theoretical Physics, Division of Computational Biology and Biological Physics, Lund University, Lund, Sweden
| | - Ulf Ekelund
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden; Skåne University Hospital Lund, Lund, Sweden
| | - Lina Dahlén Holmqvist
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Sahlgrenska University Hospitals, Gothenburg, Sweden
| | - Markus Lingman
- Halland Hospital, Region Halland, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Binda F, Clari M, Nicolò G, Gambazza S, Sappa B, Bosco P, Laquintana D. Quality of dying in hospital general wards: a cross-sectional study about the end-of-life care. BMC Palliat Care 2021; 20:153. [PMID: 34641824 PMCID: PMC8507336 DOI: 10.1186/s12904-021-00862-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 09/30/2021] [Indexed: 12/02/2022] Open
Abstract
Background In the last decade, access to national palliative care programs have improved, however a large proportion of patients continued to die in hospital, particularly within internal medicine wards. Objectives To describe treatments, symptoms and clinical management of adult patients at the end of their life and explore whether these differ according to expectation of death. Methods Single-centre cross-sectional study performed in the medical and surgical wards of a large tertiary-level university teaching hospital in the north of Italy. Data on nursing interventions and diagnostic procedure in proximity of death were collected after interviewing the nurse and the physician responsible for the patient. Relationship between nursing treatments delivered and patients’ characteristics, quality of dying and nurses’ expectation about death was summarized by means of multiple correspondence analysis (MCA). Results Few treatments were found statistically associated with expectation of death in the 187 patients included. In the last 48 h, routine (70.6%) and biomarkers (41.7%) blood tests were performed, at higher extent on patients whose death was not expected. Many symptoms classified as severe were reported when death was highly expected, except for agitation and respiratory fatigue which were reported when death was moderately expected. A high Norton score and absence of anti-bedsore mattress were associated with unexpected death and poor quality of dying, as summarized by MCA. Quality of dying was perceived as good by nurses when death was moderately and highly expected. Physicians rated more frequently than nurses the quality of dying as good or very good, respectively 78.6 and 57.8%, denoting a fair agreement between the two professionals (k = 0.24, P < 0.001). The palliative care consultant was requested for only two patients. Conclusion Staff in medical and surgical wards still deal inadequately with the needs of dying people. Presence of hospital-based specialist palliative care could lead to improvements in the patients’ quality of life.
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Affiliation(s)
- Filippo Binda
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy.
| | - Marco Clari
- Department of Public Health and Paediatrics - University of Torino, Via Santena, 5, 10126, Torino, Italy
| | - Gabriella Nicolò
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Simone Gambazza
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Barbara Sappa
- Department of Healthcare Professions (General Internal Medicine Unit), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Paola Bosco
- Department of Healthcare Professions (High-dependency Unit), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Dario Laquintana
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
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Abstract
BACKGROUND Parkinson's disease is a progressive neurodegenerative disorder that negatively impacts the lives of affected people. The therapeutic benefits of treatment only decrease going forward from the time of diagnosis. Motor and non-motor symptoms alike create a heavy burden for patients and those involved in their care. Palliative care is utilized for patients with serious illnesses and when integrated into patients with Parkinson's disease, improves quality of life by addressing symptoms of discomfort, which ultimately reduces symptom burden to patients and alleviates caregiver stress. OBJECTIVE This review aims to assess the efficacy of palliative care in the management of Parkinson's disease by exploring the benefits of palliative care integration throughout multiple relevant themes to demonstrate the optimal care delivery. METHODS Comprehensive searches on the role of palliative care in Parkinson's disease patients within MEDLINE, PUBMED, CINAHL, CENTRAL, PsycINFO, Embase, and BioMed Central, considering publications between March 2010 - February 2020 were performed. A grey literature search was also performed for additional information. RESULTS Analysis of various existing literature has demonstrated promise in timely palliative care integration for patients with Parkinson's disease, which has shown improvement in the quality of life of Parkinson's disease patients. It also strives to alleviate caregivers' stress and improve their quality of life, although insufficient research exists to support this. Palliative care in Parkinson's disease is a growing area of interest, evidently demonstrating the potential to expand among the current approaches. CONCLUSION Understanding the connections between the themes surrounding palliative care is crucial for successful integration in Parkinson's disease management. It is determined that integration of palliative care in patients with Parkinson's disease help to not only improve patients' experiences but also their caregiver's experiences throughout the disease trajectory. Further research should be conducted to address how palliative care will focus on alleviating caregiver burden and establish specific prognostication tools for Parkinson's disease patients.
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Affiliation(s)
- Helen Senderovich
- Department of Family and Community Medicine, Division of Palliative Care, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, Baycrest, Toronto, Canada
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Tripp D, Janis J, Jarrett B, Lucas FL, Strout TD, Han PKJ, Stumpf I, Hutchinson RN. How Well Does the Surprise Question Predict 1-year Mortality for Patients Admitted with COPD? J Gen Intern Med 2021; 36:2656-2662. [PMID: 33409886 PMCID: PMC8390592 DOI: 10.1007/s11606-020-06512-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/17/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) often receive burdensome care at end-of-life (EOL) and infrequently complete advance care planning (ACP). The surprise question (SQ) is a prognostic tool that may facilitate ACP. OBJECTIVE To assess how well the SQ predicts mortality and prompts ACP for COPD patients. DESIGN Retrospective cohort study. SUBJECTS Patients admitted to the hospital for an acute exacerbation of COPD between July 2015 and September 2018. MAIN MEASURES Emergency department (ED) and inpatient clinicians answered, "Would you be surprised if this patient died in the next 30 days (ED)/one year (inpatient)?" The primary outcome measure was the accuracy of the SQ in predicting 30-day and 1-year mortality. The secondary outcome was the correlation between SQ and ACP (palliative care consultation, documented goals-of-care conversation, change in code status, or completion of ACP document). KEY RESULTS The 30-day SQ had a high specificity but low sensitivity for predicting 30-day mortality: sensitivity 12%, specificity 95%, PPV 11%, and NPV 96%. The 1-year SQ demonstrated better accuracy for predicting 1-year mortality: sensitivity 47%, specificity 75%, PPV 35%, and NPV 83%. After multivariable adjustment for age, sex, and prior 6-month admissions, 1-year SQ+ responses were associated with greater odds of 1-year mortality (OR 2.38, 95% CI 1.39-4.08) versus SQ-. One-year SQ+ patients were more likely to have a goals-of-care conversation (25% vs. 11%, p < 0.01) and complete an advance directive or POLST (46% vs. 23%, p < 0.01). After multivariable adjustment, SQ+ responses to the 1-year SQ were associated with greater odds of ACP receipt (OR 2.67, 95% CI 1.64-4.36). CONCLUSIONS The 1-year surprise question may be an effective component of prognostication and advance care planning for COPD patients in the inpatient setting.
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Affiliation(s)
- Dana Tripp
- Tufts University School of Medicine, Boston, MA, USA
| | - Jaclyn Janis
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - Benjamin Jarrett
- Division of Pulmonary Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - Tania D Strout
- Tufts University School of Medicine, Boston, MA, USA.,Department of Emergency Medicine, Maine Medical Center, Portland, ME, USA
| | - Paul K J Han
- Tufts University School of Medicine, Boston, MA, USA.,Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - Isabella Stumpf
- Tufts University School of Medicine, Boston, MA, USA.,Division of Palliative Medicine, Maine Medical Center, Portland, ME, USA
| | - Rebecca N Hutchinson
- Tufts University School of Medicine, Boston, MA, USA. .,Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA. .,Division of Palliative Medicine, Maine Medical Center, Portland, ME, USA.
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87
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Welsch K, Gottschling S. Wishes and Needs at the End of Life. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:303-312. [PMID: 34180804 DOI: 10.3238/arztebl.m2021.0141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 09/19/2020] [Accepted: 01/27/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Managing the last phase of life properly, i.e., taking care that a patient's wishes are respected at the end of life and beyond, is very important and can relieve the patient and his or her family of unnecessary burdens. METHODS This review is based on guidelines, reviews, meta-analyses, selected publications, and the authors' own experiences from everyday clinical practice. RESULTS Most patients want frank information from their physicians about their condition at all times over the course of their treatment, from the moment of diagnosis to the end of their life. This has no lasting adverse effects, but rather enables patients to take decisions that are appropriate to their stage of disease. Early integration in palliative care can improve patients' quality of life, symptom control, and mood. In helping to manage the last phase of life, the physician often serves as a provider of impulses, or else determines which other types of professional should counsel or support the patient. Patients should be enabled to issue directives that reflect their wishes, as well as to choose representatives who are allowed to speak for them. Consideration should also be given to the patient's emotional legacy, e.g., letters or video messages with personal content. CONCLUSION In the care of patients with life-limiting diseases, more attention should be paid to the management of the last phase of life. Palliative-care physicians can take over this task from other medical disciplines, and early integration in palliative care is recommended.
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Affiliation(s)
- Katja Welsch
- Centre of Palliative Care and Pediatric Pain, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar
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88
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McArthur C, Hillier L, Ioannidis G, Adachi JD, Giangregorio L, Hirdes J, Papaioannou A. Developing a Fracture Risk Clinical Assessment Protocol for Long-Term Care: A Modified Delphi Consensus Process. J Am Med Dir Assoc 2021; 22:1726-1734.e8. [PMID: 32972869 DOI: 10.1016/j.jamda.2020.08.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/21/2020] [Accepted: 08/13/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To develop a fracture risk Clinical Assessment Protocol (CAP) based on long-term care (LTC) fracture prevention recommendations and an embedded fracture risk assessment tool. DESIGN A modified Delphi consensus approach including 2 survey rounds and a face-to-face meeting was implemented to reach consensus on matching of LTC fracture prevention guideline statements to Fracture Risk Scale (FRS) risk levels. SETTING AND PARTICIPANTS A national panel of recognized experts in osteoporosis, fractures, and long-term care, including an LTC resident and family members. METHODS Round 1 survey respondents (n = 24) were provided the LTC fracture prevention guidelines matched to FRS risk levels and were asked whether they agreed the guideline was appropriate for the risk level (yes, no, I don't know, I agree with some but not all of it) and to provide comments. In round 2, guideline statements that did not achieve consensus (≥80% agreement) were revised consistent with comments provided in round 1 and respondents were asked again if they agreed with the guideline statement. Statements that did not achieve consensus were to be discussed and resolved in an in-person meeting (n = 17). RESULTS In round 1 (75% response rate), consensus was achieved in 7/14 guideline statements. In round 2 (56% response rate), 5 statements were revised based on round 1 feedback and for 2 statements additional information was provided. Consensus was achieved in all but one statement related to the inappropriateness of pharmacologic therapy for residents with life expectancy less than 1 year. Following facilitated meeting discussions, consensus was obtained to revise the guideline statement to reflect that life expectancy was but one of several criteria that should be used to inform medication decisions. CONCLUSIONS AND IMPLICATIONS An evidence-based fracture risk CAP was developed that will be embedded in international routine clinical assessment tools to guide fracture prevention in LTC.
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Affiliation(s)
- Caitlin McArthur
- McMaster University, Hamilton, Ontario, Canada; GERAS Centre for Aging Research, Hamilton, Ontario, Canada.
| | | | - George Ioannidis
- McMaster University, Hamilton, Ontario, Canada; GERAS Centre for Aging Research, Hamilton, Ontario, Canada
| | | | - Lora Giangregorio
- University of Waterloo, Waterloo, Ontario, Canada; Schlegel-UW Research Institute for Aging, Hamilton, Ontario, Canada
| | - John Hirdes
- University of Waterloo, Waterloo, Ontario, Canada
| | - Alexandra Papaioannou
- McMaster University, Hamilton, Ontario, Canada; GERAS Centre for Aging Research, Hamilton, Ontario, Canada
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89
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Dujardin J, Schuurmans J, Westerduin D, Wichmann AB, Engels Y. The COVID-19 pandemic: A tipping point for advance care planning? Experiences of general practitioners. Palliat Med 2021; 35:1238-1248. [PMID: 34041987 DOI: 10.1177/02692163211016979] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2020, the COVID-19 pandemic caused an acute risk of deterioration and dying for many, and an urgent need to start advance care planning. AIM To explore how general practitioners (GPs) experienced discussing values, goals and preferences with patients during COVID-19. DESIGN AND SETTING Qualitative research in general practice. METHODS Semi-structured interviews for which Dutch GPs were recruited via purposive sampling. Content analysis was used. RESULTS Fifteen GPs were interviewed. Six themes were identified: (i) urge of advance care planning, (ii) the GP's perceived role in it, (iii) preparations for it, (iv) (proactively) discussing it, (v) essentials for good communication and (vi) advance care planning in the (near) future. Calls for proactively discussing advance care planning in the media and in COVID-guidelines caused awareness of it's importance. GPs envisaged an important role for themselves in initiating it, especially with patients at risk to deteriorate or die from COVID-19. Timing advance care planning appeared difficult but crucial. The recommended digital way of communication was considered problematic due to missing nonverbal communication and difficulties in involving relatives. It was noted that admission to the ICU, which was hardly discussed before the COVID-19 pandemic, should remain a topic during advance care planning. CONCLUSION The COVID-19 pandemic brought advance care planning into a new light, GPs were more experienced with discussing it and patients were more aware of their frailty. Because of the nearing 'grey wave', advance care planning should remain top priority. Therefore, it should be central in GP and post-academic training.
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Affiliation(s)
- Janneke Dujardin
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Jaap Schuurmans
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Dieke Westerduin
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Anne B Wichmann
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud university medical centre, Nijmegen, The Netherlands
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90
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Gajra A, Zettler ME, Miller KA, Blau S, Venkateshwaran SS, Sridharan S, Showalter J, Valley AW, Frownfelter JG. Augmented intelligence to predict 30-day mortality in patients with cancer. Future Oncol 2021; 17:3797-3807. [PMID: 34189965 DOI: 10.2217/fon-2021-0302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Aim: An augmented intelligence tool to predict short-term mortality risk among patients with cancer could help identify those in need of actionable interventions or palliative care services. Patients & methods: An algorithm to predict 30-day mortality risk was developed using socioeconomic and clinical data from patients in a large community hematology/oncology practice. Patients were scored weekly; algorithm performance was assessed using dates of death in patients' electronic health records. Results: For patients scored as highest risk for 30-day mortality, the event rate was 4.9% (vs 0.7% in patients scored as low risk; a 7.4-times greater risk). Conclusion: The development and validation of a decision tool to accurately identify patients with cancer who are at risk for short-term mortality is feasible.
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Affiliation(s)
- Ajeet Gajra
- Cardinal Health Specialty Solutions, Dublin, OH 43017, USA
| | | | | | - Sibel Blau
- Rainier Hematology Oncology/Northwest Medical Specialties, Tacoma, WA 98405, USA
| | | | | | | | - Amy W Valley
- Cardinal Health Specialty Solutions, Dublin, OH 43017, USA
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91
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Ernecoff NC, Abdel-Kader K, Cai M, Yabes J, Shah N, Schell JO, Jhamb M. Implementation of Surprise Question Assessments using the Electronic Health Record in Older Adults with Advanced CKD. KIDNEY360 2021; 2:966-973. [PMID: 35373084 PMCID: PMC8791363 DOI: 10.34067/kid.0007062020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
Background The Surprise Question (SQ; "Would you be surprised if this patient died in the next 12 months?") is a validated prognostication tool for mortality and hospitalization among patients with advanced CKD. Barriers in clinical workflows have slowed SQ implementation in practice. Objectives The aims of this study were: (1) to evaluate implementation outcomes after the use of electronic health record (EHR) decision support to automate the collection of the SQ; and (2) to assess the prognostic utility of the SQ for mortality and hospitalization/emergency room (ER) visits. Methods We developed and implemented a best practice alert (BPA) in the EHR to identify nephrology outpatients ≥60 years of age with an eGFR <30 ml/min per 1.73 m2. At appointment, the BPA prompted the physician to answer the SQ. We assessed the rate and timeliness of provider responses. We conducted a post-hoc open-ended survey to assess physician perceptions of SQ implementation. We assessed the SQ's prognostic utility in survival and time-to-hospital encounter (hospitalization/ER visit) analyses. Results Among 510 patients for whom the BPA triggered, 95 (19%) had the SQ completed by 16 physicians. Among those completed, nearly all (98%) were on appointment day, and 61 (64%) the first time the BPA fired. Providers answered "no" for 27 (28%) and "yes" for 68 (72%) patients. By 12 months, six (22%) "no" patients died; three (4%) "yes" patients died (hazard ratio [HR] 2.86, ref: yes, 95% CI, 1.06 to 7.69). About 35% of "no" patients and 32% of "yes" patients had a hospital encounter by 12 months (HR, 1.85, ref: yes, 95% CI, 0.93 to 3.69). Physicians noted (1) they had goals-of-care conversations unprompted; (2) EHR-based interventions alone for goals-of-care are ineffective; and (3) more robust engagement is necessary. Conclusions We successfully integrated the SQ into the EHR to aid in clinical practice. Additional implementation efforts are needed to encourage further integration of the SQ in clinical practice.
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Affiliation(s)
- Natalie C. Ernecoff
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University, Nashville, Tennessee
| | - Manqi Cai
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan Yabes
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nirav Shah
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane O. Schell
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Manisha Jhamb
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
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92
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"The surprise questions" using variable time frames in hospitalized patients with advanced cancer. Palliat Support Care 2021; 20:221-225. [PMID: 34134807 DOI: 10.1017/s1478951521000766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Several studies supported the usefulness of "the surprise question" in terms of 1-year mortality of patients. "The surprise question" requires a "Yes" or "No" answer to the question "Would I be surprised if this patient died in [specific time frame]." However, the 1-year time frame is often too long for advanced cancer patients seen by palliative care personnel. "The surprise question" with shorter time frames is needed for decision making. We examined the accuracy of "the surprise question" for 7-day, 21-day, and 42-day survival in hospitalized patients admitted to palliative care units (PCUs). METHOD This was a prospective multicenter cohort study of 130 adult patients with advanced cancer admitted to 7 hospital-based PCUs in South Korea. The accuracy of "the surprise question" was compared with that of the temporal question for clinician's prediction of survival. RESULTS We analyzed 130 inpatients who died in PCUs during the study period. The median survival was 21.0 days. The sensitivity, specificity, and overall accuracy for the 7-day "the surprise question" were 46.7, 88.7, and 83.9%, respectively. The sensitivity, specificity, and overall accuracy for the 7-day temporal question were 6.7, 98.3, and 87.7%, respectively. The c-indices of the 7-day "the surprise question" and 7-day temporal question were 0.662 (95% CI: 0.539-0.785) and 0.521 (95% CI: 0.464-0.579), respectively. The c-indices of the 42-day "the surprise question" and 42-day temporal question were 0.554 (95% CI: 0.509-0.599) and 0.616 (95% CI: 0.569-0.663), respectively. SIGNIFICANCE OF RESULTS Surprisingly, "the surprise questions" and temporal questions had similar accuracies. The high specificities for the 7-day "the surprise question" and 7- and 21-day temporal question suggest they may be useful to rule in death if positive.
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93
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Yoon SJ, Suh SY, Hui D, Choi SE, Tatara R, Watanabe H, Otani H, Morita T. Accuracy of the Palliative Prognostic Score With or Without Clinicians' Prediction of Survival in Patients With Far Advanced Cancer. J Pain Symptom Manage 2021; 61:1180-1187. [PMID: 33096217 DOI: 10.1016/j.jpainsymman.2020.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Previous studies suggest that clinicians' prediction of survival (CPS) may have reduced the accuracy of objective indicators for prognostication in palliative care. OBJECTIVES We aimed to examine the accuracy of CPS alone, compared to the original Palliative Prognostic Score (PaP), and five clinical/laboratory variables of the PaP in patients with far advanced cancer. METHODS We compared the discriminative accuracy of three prediction models (the PaP-CPS [the score of the categorical CPS of PaP], PaP without CPS [sum of the scores of only the objective variables of PaP], and PaP total score) across 3 settings: inpatient palliative care consultation team, palliative care unit, and home palliative care. We computed the area under receiver operating characteristic curve (AUROC) for 30-day survival and concordance index (C-index) to compare the discriminative accuracy of these three models. RESULTS We included a total of 1534 subjects with median survival of 34.0 days. The AUROC and C-index in the three settings were 0.816-0.896 and 0.732-0.799 for the PaP total score, 0.808-0.884 and 0.713-0.782 for the PaP-CPS, and 0.726-0.815 and 0.672-0.728 for the PaP without CPS, respectively. The PaP total score and PaP-CPS showed similar AUROCs and C-indices across the three settings. The PaP total score had significantly higher AUROCs and C-indices than the PaP without CPS across the three settings. CONCLUSION Overall, the PaP total score, PaP-CPS, and PaP without CPS showed good discriminative performances. However, the PaP total score and PaP-CPS were significantly more accurate than the PaP without CPS.
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Affiliation(s)
- Seok-Joon Yoon
- Department of Family Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Sang-Yeon Suh
- Department of Medicine, Dongguk University-Seoul, Seoul, South Korea; Department of Family Medicine, Hospice and Palliative Care Center, Dongguk University Ilsan Hospital, Goyang-si, South Korea.
| | - David Hui
- Division of Cancer Medicine, Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sung-Eun Choi
- Department of Statistics, Dongguk University-Seoul, Seoul, South Korea
| | - Ryohei Tatara
- Department of Palliative Medicine, Osaka City General Hospital, Osaka, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Hiroyuki Otani
- Department of Palliative Care Team and Palliative and Supportive Care, National Kyushu Cancer Center, Fukuoka, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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Årestedt K, Brännström M, Evangelista LS, Strömberg A, Alvariza A. Palliative key aspects are of importance for symptom relief during the last week of life in patients with heart failure. ESC Heart Fail 2021; 8:2202-2209. [PMID: 33754461 PMCID: PMC8120384 DOI: 10.1002/ehf2.13312] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/14/2021] [Accepted: 03/05/2021] [Indexed: 01/05/2023] Open
Abstract
AIMS This study aimed to describe symptom prevalence of pain, shortness of breath, anxiety, and nausea and to identify factors associated with symptom relief in patients with heart failure during their last week of life. METHODS AND RESULTS This nationwide study used data from the Swedish Register of Palliative Care and the Swedish Causes of Death Certificate Register. The sample included 4215 patients with heart failure as the underlying cause of death. Descriptive statistics and logistic regression were used to analyse data. Pain was the most prevalent symptom (64.0%), followed by anxiety (45.1%), shortness of breath (28.8%), and nausea (11.4%). Pain was the most often totally relieved (77.5%), followed by anxiety (68.4%), nausea (54.7%), and shortness of breath (37.1%). Key aspects of palliative care such as documented palliative care in the patient record, individual medication prescriptions by injection, symptom assessment with validated scales, documented end-of-life discussions with patients and/or family members, and external consultation were significantly associated with symptom relief. Relief of pain, shortness of breath, anxiety, and nausea were significantly better managed in nursing homes and hospice/inpatient palliative care compared with care in hospitals. CONCLUSIONS The results show that key aspects of palliative care during the last week of life are significantly associated with symptom relief. Increased access to palliative care could provide a way to improve care during the last week of life for patients with heart failure. Home-based settings provided more symptom relief than hospitals, which may indicate that the latter focuses on treatments and saving lives rather than promoting life before death.
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Affiliation(s)
- Kristofer Årestedt
- Faculty of Health and Life SciencesLinnaeus UniversityKalmarSE‐39182Sweden
- The Research SectionKalmar County CouncilKalmarSweden
| | | | | | - Anna Strömberg
- Department of Health, Medicine and Caring Sciences and Department of CardiologyLinköping UniversityLinköpingSweden
- Department of CardiologyLinköping UniversityLinköpingSweden
| | - Anette Alvariza
- Department of Health Care Sciences & Palliative Research CentreErsta Sköndal Bräcke University CollegeStockholmSweden
- Capio Palliative CareDalen HospitalStockholmSweden
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95
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Piers R, De Brauwer I, Baeyens H, Velghe A, Hens L, Deschepper E, Henrard S, De Pauw M, Van Den Noortgate N, De Saint-Hubert M. Supportive and Palliative Care Indicators Tool prognostic value in older hospitalised patients: a prospective multicentre study. BMJ Support Palliat Care 2021:bmjspcare-2021-003042. [PMID: 34059507 DOI: 10.1136/bmjspcare-2021-003042] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/09/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND An increasing number of older patients are hospitalised. Prognostic uncertainty causes hospital doctors to be reluctant to make the switch from cure to care. The Supportive and Palliative Care Indicators Tool (SPICT) has not been validated for prognostication in an older hospitalised population. AIM To validate SPICT as a prognostic tool for risk of dying within one year in older hospitalised patients. DESIGN Prospective multicentre study. Premorbid SPICT and 1-year survival and survival time were assessed. SETTING/PARTICIPANTS Patients 75 years and older admitted at acute geriatric (n=209) and cardiology units (CUs) (n=249) of four hospitals. RESULTS In total, 59.3% (124/209) was SPICT identified on acute geriatric vs 40.6% (101/249) on CUs (p<0.001). SPICT-identified patients in CUs reported more functional needs and more symptoms compared to SPICT non-identified patients. On acute geriatric units, SPICT-identified patients reported more functional needs only.The HR of dying was 2.9 (95% CI 1.1 to 8.7) in SPICT-identified versus non-identified after adjustment for hospital strata, age, gender and did not differ between units. One-year mortality was 24% and 22%, respectively, on acute geriatric versus CUs (p=0.488). Pooled average sensitivity, specificity and partial area under the curve differed significantly between acute geriatric and CUs (p<0.001), respectively, 0.82 (95%CI 0.66 to 0.91), 0.49 (95%CI 0.40 to 0.58) and 0.82 in geriatric vs 0.69 (95% CI 0.42 to 0.87), 0.66 (95% CI 0.55 to 0.77) and 0.65 in CUs. CONCLUSIONS SPICT may be used as a tool to identify older hospitalised patients at risk of dying within 1 year and who may benefit from a palliative care approach including advance care planning. The prognostic accuracy of SPICT is better in older patients admitted at the acute geriatric versus the CU.
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Affiliation(s)
- Ruth Piers
- Department of Geriatric Medicine, University Hospital Ghent, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium
| | - Isabelle De Brauwer
- Department of Geriatric Medicine, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
- UCL Institute of Health and Society, Bruxelles, Belgium
| | - Hilde Baeyens
- Department of Geriatric Medicine, AZ Alma campus Eeklo, Eeklo, Belgium
| | - Anja Velghe
- Department of Geriatric Medicine, University Hospital Ghent, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium
| | - Lineke Hens
- Department of Cardiology, University Hospital Ghent, Ghent, Belgium
| | - Ellen Deschepper
- Biostatistics Unit, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Séverine Henrard
- UCL Institute of Health and Society, Bruxelles, Belgium
- UCLouvain Louvain Drug Research Institute, Bruxelles, Belgium
| | - Michel De Pauw
- Department of Internal Medicine and Pediatrics, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium
- Department of Cardiology, University Hospital Ghent, Ghent, Belgium
| | - Nele Van Den Noortgate
- Department of Geriatric Medicine, University Hospital Ghent, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium
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Moor CC, Tak van Jaarsveld NC, Owusuaa C, Miedema JR, Baart S, van der Rijt CCD, Wijsenbeek MS. The Value of the Surprise Question to Predict One-Year Mortality in Idiopathic Pulmonary Fibrosis: A Prospective Cohort Study. Respiration 2021; 100:780-785. [PMID: 34044401 DOI: 10.1159/000516291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is a progressive fatal disease with a heterogeneous disease course. Timely initiation of palliative care is often lacking. The surprise question "Would you be surprised if this patient died within the next year?" is increasingly used as a clinical prognostic tool in chronic diseases but has never been evaluated in IPF. OBJECTIVE We aimed to evaluate the predictive value of the surprise question for 1-year mortality in IPF. METHODS In this prospective cohort study, clinicians answered the surprise question for each included patient. Clinical parameters and mortality data were collected. The sensitivity, specificity, accuracy, negative, and positive predictive value of the surprise question with regard to 1-year mortality were calculated. Multivariable logistic regression analysis was performed to evaluate which factors were associated with mortality. In addition, discriminative performance of the surprise question was assessed using the C-statistic. RESULTS In total, 140 patients were included. One-year all-cause mortality was 20% (n = 28). Clinicians identified patients with a survival of <1 year with a sensitivity of 68%, a specificity of 82%, an accuracy of 79%, a positive predictive value of 49%, and a negative predictive value of 91%. The surprise question significantly predicted 1-year mortality in a multivariable model (OR 3.69; 95% CI 1.24-11.02; p = 0.019). The C-statistic of the surprise question to predict mortality was 0.75 (95% CI 0.66-0.85). CONCLUSIONS The answer on the surprise question can accurately predict 1-year mortality in IPF. Hence, this simple tool may enable timely focus on palliative care for patients with IPF.
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Affiliation(s)
- Catharina C Moor
- Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Catherine Owusuaa
- Erasmus MC Cancer Institute, Department of Medical Oncology, Rotterdam, The Netherlands
| | - Jelle R Miedema
- Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sara Baart
- Department of Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Marlies S Wijsenbeek
- Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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97
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Stone P, Vickerstaff V, Kalpakidou A, Todd C, Griffiths J, Keeley V, Spencer K, Buckle P, Finlay D, Omar RZ. Prognostic tools or clinical predictions: Which are better in palliative care? PLoS One 2021; 16:e0249763. [PMID: 33909658 PMCID: PMC8081205 DOI: 10.1371/journal.pone.0249763] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/25/2021] [Indexed: 01/29/2023] Open
Abstract
PURPOSE The Palliative Prognostic (PaP) score; Palliative Prognostic Index (PPI); Feliu Prognostic Nomogram (FPN) and Palliative Performance Scale (PPS) have all been proposed as prognostic tools for palliative cancer care. However, clinical judgement remains the principal way by which palliative care professionals determine prognoses and it is important that the performance of prognostic tools is compared against clinical predictions of survival (CPS). METHODS This was a multi-centre, cohort validation study of prognostic tools. Study participants were adults with advanced cancer receiving palliative care, with or without capacity to consent. Key prognostic data were collected at baseline, shortly after referral to palliative care services. CPS were obtained independently from a doctor and a nurse. RESULTS Prognostic data were collected on 1833 participants. All prognostic tools showed acceptable discrimination and calibration, but none showed superiority to CPS. Both PaP and CPS were equally able to accurately categorise patients according to their risk of dying within 30 days. There was no difference in performance between CPS and FPN at stratifying patients according to their risk of dying at 15, 30 or 60 days. PPI was significantly (p<0.001) worse than CPS at predicting which patients would survive for 3 or 6 weeks. PPS and CPS were both able to discriminate palliative care patients into multiple iso-prognostic groups. CONCLUSIONS Although four commonly used prognostic algorithms for palliative care generally showed good discrimination and calibration, none of them demonstrated superiority to CPS. Prognostic tools which are less accurate than CPS are of no clinical use. However, prognostic tools which perform similarly to CPS may have other advantages to recommend them for use in clinical practice (e.g. being more objective, more reproducible, acting as a second opinion or as an educational tool). Future studies should therefore assess the impact of prognostic tools on clinical practice and decision-making.
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Affiliation(s)
- P. Stone
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London (UCL), London, United Kingdom
| | - V. Vickerstaff
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London (UCL), London, United Kingdom
| | - A. Kalpakidou
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London (UCL), London, United Kingdom
| | - C. Todd
- Faculty of Biology, Medicine and Health, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - J. Griffiths
- Faculty of Biology, Medicine and Health, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - V. Keeley
- Palliative Medicine Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom
| | - K. Spencer
- Faculty of Biology, Medicine and Health, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - P. Buckle
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London (UCL), London, United Kingdom
| | - D. Finlay
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London (UCL), London, United Kingdom
| | - R. Z. Omar
- Department of Statistical Science, University College London (UCL), London, United Kingdom
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98
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Lewis ET, Harrison R, Nicholson M, Hillman K, Trankle S, Rangel S, Stokes C, Cardona M. Clinicians' and public acceptability of universal risk-of-death screening for older people in routine clinical practice in Australia: cross-sectional surveys. Aging Clin Exp Res 2021; 33:1063-1070. [PMID: 32458357 DOI: 10.1007/s40520-020-01598-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Clinicians' delays to identify risk of death and communicate it to patients nearing the end of life contribute to health-related harm in health services worldwide. This study sought to ascertain doctors, nurses and senior members of the public's perceptions of the routine use of a screening tool to predict risk of death for older people. METHODS Cross-sectional online, face-to-face and postal survey of 360 clinicians and 497 members of the public. RESULTS Most (65.9%) of the members of the public welcomed (and 12.3% were indifferent to) the use of a screening tool as a decision guide to minimise overtreatment and errors from clinician assumptions. Supporters of the use of a prognostic tool were likely to be males with high social capital, chronically ill and who did not have an advance health directive. The majority of clinicians (75.6%) reported they were likely or very likely to use the tool, or might consider using it if convinced of its accuracy. A minority (13.3%) stated they preferred to rely on their clinical judgement and would be unlikely to use it. Differentials in support for tools by seniority were observed, with more support expressed by nurses, interns and registrars than medical specialists (χ2 = 12.95, p = 0.044) and by younger (< 40 years) clinicians (81.2% vs. 71.2%, p = 0.0058). DISCUSSION The concept of integrating prognostication of death in routine practice was not resisted by either target group. CONCLUSION Findings indicate that screening for risk of death is seen as potentially useful and suggests the readiness for a culture change. Future research on implementation strategies could be a step in the right direction.
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99
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Le K, Lee J, Desai S, Ho A, van Heukelom H. The Surprise Question and Serious Illness Conversations: A pilot study. Nurs Ethics 2021; 28:1010-1025. [PMID: 33686904 DOI: 10.1177/0969733020983392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Serious Illness Conversations aim to discuss patient goals. However, on acute medicine units, seriously ill patients may undergo distressing interventions until death. OBJECTIVES To investigate the feasibility of using the Surprise Question, "Would you be surprised if this patient died within the next year?" to identify patients who would benefit from early Serious Illness Conversations and study any changes in the interdisciplinary team's beliefs, confidence, and engagement as a result of asking the Surprise Question. DESIGN A prospective cohort pilot study with two Plan-Do-Study-Act cycles. PARTICIPANTS/CONTEXT Fifty-eight healthcare professionals working on Acute Medicine Units participated in pre- and post-intervention questionnaires. The intervention involved asking participants the Surprise Question for each patient. Patient charts were reviewed for Serious Illness Conversation documentation. ETHICAL CONSIDERATIONS Ethical approval was granted by the institutions involved. FINDINGS Equivocal overall changes in the beliefs, confidence, and engagement of healthcare professionals were observed. Six out of 23 patients were indicated as needing a Serious Illness Conversation; chart review provided some evidence that these patients had more Serious Illness Conversation documentation compared with the 17 patients not flagged for a Serious Illness Conversation. Issues were identified in equating the Surprise Question to a Serious Illness Conversation. DISCUSSION Appropriate support for seriously ill patients is both a nursing professional and ethical duty. Flagging patients for conversations may act as a filtering process, allowing healthcare professionals to focus on conversations with patients who need them most. There are ethical and practical issues as to what constitutes a "serious illness" and if answering "no" to the Surprise Question always equates to a conversation. CONCLUSION The barriers of time constraints and lack of training call for institutional change in order to prioritise the moral obligation of Serious Illness Conversations.
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Affiliation(s)
| | - Jenny Lee
- 102794Providence Health Care, Canada
| | - Sameer Desai
- Centre for Health Evaluation and Outcome Sciences, Canada
| | - Anita Ho
- 8166University of British Columbia, Canada; University of California San Francisco, USA; Centre for Health Evaluation and Outcome Sciences, Canada
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100
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Ermers DJM, Kuip EJM, Veldhoven CMM, Schers HJ, Perry M, Bronkhorst EM, Vissers KCP, Engels Y. Timely identification of patients in need of palliative care using the Double Surprise Question: A prospective study on outpatients with cancer. Palliat Med 2021; 35:592-602. [PMID: 33423610 PMCID: PMC7975860 DOI: 10.1177/0269216320986720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The Surprise Question ("Would I be surprised if this patient were to die within the next 12 months?") is widely used to identify palliative patients, though with low predictive value. To improve timely identification of palliative care needs, we propose an additional Surprise Question ("Would I be surprised if this patient is still alive after 12 months?") if the original Surprise Question is answered with "no." The combination of the two questions is called the Double Surprise Question. AIM To examine the prognostic accuracy of the Double Surprise Question in outpatients with cancer. DESIGN A prospective study. PARTICIPANTS Twelve medical oncologists completed the Double Surprise Question for 379 patients. RESULTS In group 1 (original Surprise Question "yes": surprised if dead) 92.1% (176/191) of the patients were still alive after 1 year, in group 2a (original and additional Surprise Question "no": not surprised if dead and not surprised if alive) 60.0% (63/105), and in group 2b (original Surprise Question "no," additional Surprise Question "yes": surprised if alive) 26.5% (22/83) (p < 0.0001). The positive predictive value increased by using the Double Surprise Question; 74% (61/83) vs 55% (103/188). Anticipatory palliative care provision and Advance Care Planning items were most often documented in group 2b. CONCLUSIONS The Double Surprise Question is a promising tool to more accurately identify outpatients with cancer at risk of dying within 1 year, and therefore, those in need of palliative care. Studies should reveal whether the implementation of the Double Surprise Question leads to more timely palliative care.
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Affiliation(s)
- Daisy JM Ermers
- Department of Anesthesiology, Pain and
Palliative Medicine, Radboud University Medical Center, Nijmegen, The
Netherlands
| | - Evelien JM Kuip
- Department of Anesthesiology, Pain and
Palliative Medicine, Radboud University Medical Center, Nijmegen, The
Netherlands
- Department of Medical Oncology, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - CMM Veldhoven
- Department of Anesthesiology, Pain and
Palliative Medicine, Radboud University Medical Center, Nijmegen, The
Netherlands
- General Practice Berg en Dal, Berg en
Dal, The Netherlands
| | - Henk J Schers
- Department of Primary and Community
Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke Perry
- Department of Primary and Community
Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Geriatrics, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Ewald M Bronkhorst
- Department of Health Evidence, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Kris CP Vissers
- Department of Anesthesiology, Pain and
Palliative Medicine, Radboud University Medical Center, Nijmegen, The
Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and
Palliative Medicine, Radboud University Medical Center, Nijmegen, The
Netherlands
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