101
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Rodriquez J, Boerner K. Social and organizational practices that influence hospice utilization in nursing homes. J Aging Stud 2018; 46:76-81. [PMID: 30100120 DOI: 10.1016/j.jaging.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/07/2018] [Accepted: 06/23/2018] [Indexed: 11/18/2022]
Abstract
Hospice has grown considerably but the likelihood that someone gets hospice depends on social and organizational practices. This article shows how staff beliefs and work routines influenced hospice utilization in two nursing homes. In one, 76% of residents died on hospice and in the other 24% did. Staff identified barriers to hospice including families who saw hospice as giving up and gaps in the reimbursement system. At the high-hospice nursing home, staff said hospice care extended beyond what they provided on their own. At the low-hospice nursing home, an influential group said hospice was essentially the same as their own end-of-life care and therefore needlessly duplicative. Staff at the high-hospice nursing home proactively approached families about hospice, whereas staff at the low-hospice nursing home took a reactive approach, getting hospice when families asked for it. Findings demonstrate how staff beliefs and practices regarding hospice shape end-of-life care in nursing homes.
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Affiliation(s)
- Jason Rodriquez
- Department of Sociology, University of Massachusetts - Boston, Boston, MA, United States.
| | - Kathrin Boerner
- Department of Gerontology, University of Massachusetts - Boston, Boston, MA, United States.
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102
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Sulmasy DP, Finlay I, Fitzgerald F, Foley K, Payne R, Siegler M. Physician-Assisted Suicide: Why Neutrality by Organized Medicine Is Neither Neutral Nor Appropriate. J Gen Intern Med 2018; 33:1394-1399. [PMID: 29722005 PMCID: PMC6082198 DOI: 10.1007/s11606-018-4424-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 12/15/2017] [Accepted: 03/27/2018] [Indexed: 12/25/2022]
Abstract
It has been proposed that medical organizations adopt neutrality with respect to physician-assisted suicide (PAS), given that the practice is legal in some jurisdictions and that membership is divided. We review developments in end-of-life care and the role of medical organizations with respect to the legalization of PAS since the 1990s. We argue that moving from opposition to neutrality is not ethically neutral, but a substantive shift from prohibited to optional. We argue that medical organizations already oppose many practices that are legal in many jurisdictions, and that unanimity among membership has not been required for any other clinical or ethical policy positions. Moreover, on an issue so central to the meaning of medical professionalism, it seems important for organized medicine to take a stand. We subsequently review the arguments in favor of PAS (arguments from autonomy and mercy, and against the distinction between killing and allowing to die (K/ATD)) and the arguments against legalization (the limits of autonomy, effects on the patient-physician relationship, the meaning of healing, the validity of the K/ATD distinction, the social nature of suicide, the availability of alternatives, the propensity for incremental extension, and the meaning of control). We conclude that organized medicine should continue its opposition to PAS.
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Affiliation(s)
- Daniel P Sulmasy
- Departments of Medicine & Philosophy, The Pellegrino Center for Clinical Bioethics, & Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA.
| | - Ilora Finlay
- Department of Palliative Medicine, Cardiff University, Cardiff, UK
| | | | - Kathleen Foley
- Memorial Sloan Kettering Cancer Center and Weill-Cornell Medical College, New York, NY, USA
| | - Richard Payne
- Duke University, Durham, NC & the Center for Practical Bioethics, Kansas City, MO, USA
| | - Mark Siegler
- MacLean Center for Clinical Medical Ethics & Department of Medicine, University of Chicago, Chicago, IL, USA
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103
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Seow H, Bainbridge D. The development of specialized palliative care in the community: A qualitative study of the evolution of 15 teams. Palliat Med 2018; 32:1255-1266. [PMID: 29737244 PMCID: PMC6041761 DOI: 10.1177/0269216318773912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Interprofessional specialized palliative care teams at home improve patient outcomes, reduce healthcare costs, and support many patients to die at home. However, practical details about how to develop home-based teams in different regions and health systems are scarce. AIM To examine how a variety of home-based specialized palliative care teams created and grew their team over time and to identify critical steps in their evolution. DESIGN A qualitative study was designed based on a grounded theory approach, using semi-structured interviews and other documentation. SETTING/PARTICIPANTS In all, 15 specialized palliative care teams from Ontario, Canada, representing rural and urban areas. Data were collected from core members of the teams, including nurses, physicians, personal support workers, spiritual counselors, and administrators. RESULTS In all, 122 individuals where interviewed, ranging from 4 to 10 per team. The analysis revealed four stages in team evolution: Inception, Start-up (n = 4 teams), Growth (n = 5), and Mature (n = 6). In the Inception stage, a champion provider was required to leverage existing resources to form the team. Start-up teams were testing and adjusting care processes to solidify their presence in the community. Growth teams had core expertise, relationships with fellow providers, and 24/7 support. Mature teams were fully integrated in the community, but still engaged in continuous quality improvement. CONCLUSION Understanding the developmental stages of teams can help to inform the progress of other community-based teams. Appropriate outcome measures at each stage are also critical for team motivation and steady progress.
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Affiliation(s)
- Hsien Seow
- 1 Department of Oncology, McMaster University, Hamilton, ON, Canada.,2 Escarpment Cancer Research Institute, Hamilton, ON, Canada.,3 Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Daryl Bainbridge
- 1 Department of Oncology, McMaster University, Hamilton, ON, Canada.,3 Juravinski Cancer Centre, Hamilton, ON, Canada
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104
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Fine PG, Davis MS, Muir JC, Byas-Smith M. Anesthesiology and Palliative Care: Past, Present, and Future. Anesth Analg 2018; 127:12-14. [PMID: 29912054 DOI: 10.1213/ane.0000000000002870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Perry G Fine
- From the Division of Pain Medicine, Department of Anesthesiology, School of Medicine, University of Utah, Salt Lake City, Utah
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105
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Increased hospice enrollment and decreased neurosurgical interventions without changes in mortality for older Medicare patients with moderate to severe traumatic brain injury. Am J Surg 2018. [DOI: 10.1016/j.amjsurg.2018.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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106
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May P, Normand C, Cassel JB, Del Fabbro E, Fine RL, Menz R, Morrison CA, Penrod JD, Robinson C, Morrison RS. Economics of Palliative Care for Hospitalized Adults With Serious Illness: A Meta-analysis. JAMA Intern Med 2018; 178:820-829. [PMID: 29710177 PMCID: PMC6145747 DOI: 10.1001/jamainternmed.2018.0750] [Citation(s) in RCA: 150] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Economics of care for adults with serious illness is a policy priority worldwide. Palliative care may lower costs for hospitalized adults, but the evidence has important limitations. OBJECTIVE To estimate the association of palliative care consultation (PCC) with direct hospital costs for adults with serious illness. DATA SOURCES Systematic searches of the Embase, PsycINFO, CENTRAL, PubMed, CINAHL, and EconLit databases were performed for English-language journal articles using keywords in the domains of palliative care (eg, palliative, terminal) and economics (eg, cost, utilization), with limiters for hospital and consultation. For Embase, PsycINFO, and CENTRAL, we searched without a time limitation. For PubMed, CINAHL, and EconLit, we searched for articles published after August 1, 2013. Data analysis was performed from April 8, 2017, to September 16, 2017. STUDY SELECTION Economic evaluations of interdisciplinary PCC for hospitalized adults with at least 1 of 7 illnesses (cancer; heart, liver, or kidney failure; chronic obstructive pulmonary disease; AIDS/HIV; or selected neurodegenerative conditions) in the hospital inpatient setting vs usual care only, controlling for a minimum list of confounders. DATA EXTRACTION AND SYNTHESIS Eight eligible studies were identified, all cohort studies, of which 6 provided sufficient information for inclusion. The study estimated the association of PCC within 3 days of admission with direct hospital costs for each sample and for subsamples defined by primary diagnoses and number of comorbidities at admission, controlling for confounding with an instrumental variable when available and otherwise propensity score weighting. Treatment effect estimates were pooled in the meta-analysis. MAIN OUTCOMES AND MEASURES Total direct hospital costs. RESULTS This study included 6 samples with a total 133 118 patients (range, 1020-82 273), of whom 93.2% were discharged alive (range, 89.0%-98.4%), 40.8% had a primary diagnosis of cancer (range, 15.7%-100.0%), and 3.6% received a PCC (range, 2.2%-22.3%). Mean Elixhauser index scores ranged from 2.2 to 3.5 among the studies. When patients were pooled irrespective of diagnosis, there was a statistically significant reduction in costs (-$3237; 95% CI, -$3581 to -$2893; P < .001). In the stratified analyses, there was a reduction in costs for the cancer (-$4251; 95% CI, -$4664 to -$3837; P < .001) and noncancer (-$2105; 95% CI, -$2698 to -$1511; P < .001) subsamples. The reduction in cost was greater in those with 4 or more comorbidities than for those with 2 or fewer. CONCLUSIONS AND RELEVANCE The estimated association of early hospital PCC with hospital costs may vary according to baseline clinical factors. Estimates may be larger for primary diagnosis of cancer and more comorbidities compared with primary diagnosis of noncancer and fewer comorbidities. Increasing palliative care capacity to meet national guidelines may reduce costs for hospitalized adults with serious and complex illnesses.
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Affiliation(s)
- Peter May
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland.,Cicely Saunders Institute of Palliative Care, Policy, and Rehabilitation, King's College London, London, England
| | - J Brian Cassel
- Massey Cancer Center, Virginia Commonwealth University, Richmond
| | | | | | | | | | - Joan D Penrod
- James J. Peters Veterans Affairs Medical Center, New York, New York.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - R Sean Morrison
- James J. Peters Veterans Affairs Medical Center, New York, New York.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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107
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Prizer LP, Gay JL, Wilson MG, Emerson KG, Glass AP, Miyasaki JM, Perkins MM. A Mixed-Methods Approach to Understanding the Palliative Needs of Parkinson’s Patients. J Appl Gerontol 2018; 39:834-845. [DOI: 10.1177/0733464818776794] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Parkinson’s disease (PD) is the second-most common age-related neurodegenerative disorder. Despite recommendations for a palliative approach, little is known about what palliative needs are unmet by standard care. This study aims to (a) identify palliative needs of PD patients, (b) determine the relationship between palliative needs and health-related quality of life (HRQoL), and (c) probe into factors affecting HRQoL. PD patients and neurologists were recruited for a survey on palliative need; a subset of patients was interviewed. Significant differences between physicians and patients were found in Physical, Psychological, Social, Financial, and Spiritual domains. Physical and Psychological needs predicted HRQoL. Primary themes across interviews included (a) lack of healthcare education and (b) need for care coordination. Secondary themes included (a) the importance of support groups, (b) the role of spirituality/religion, and (c) the narrow perceived role of the neurologist. Findings highlight the importance of coordinated individualized care.
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108
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Miller SC, Intrator O, Scott W, Shreve ST, Phibbs CS, Kinosian B, Allman RM, Edes TE. Increasing Veterans' Hospice Use: The Veterans Health Administration's Focus On Improving End-Of-Life Care. Health Aff (Millwood) 2018; 36:1274-1282. [PMID: 28679815 DOI: 10.1377/hlthaff.2017.0173] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 2009 the Department of Veterans Affairs (VA) began a major, four-year investment in improving the quality of end-of-life care. The Comprehensive End of Life Care Initiative increased the numbers of VA medical center inpatient hospice units and palliative care staff members as well as the amount of palliative care training, quality monitoring, and community outreach. We divided male veterans ages sixty-six and older into categories based on their use of the VA and Medicare and examined whether the increases in their rates of hospice use in the last year of life differed from the concurrent increase among similar nonveterans enrolled in Medicare. After adjusting for age, race and ethnicity, diagnoses, nursing home use in the last year of life, census region, and urbanicity of a person's last residence, we found a 6.9-7.9-percentage-point increase in hospice use over time for the veteran categories, compared to a 5.6-percentage-point increase for nonveterans (the relative increases were 20-42 percent and 16 percent, respectively). The VA's substantial investment in palliative care appears to have resulted in greater hospice use by older male veterans enrolled in the VA, a critical step forward in caring for veterans with serious illnesses.
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Affiliation(s)
- Susan C Miller
- Susan C. Miller is a professor of health services, policy, and practice at the Center for Gerontology and Health Care Research, Brown University School of Public Health, in Providence, Rhode Island
| | - Orna Intrator
- Orna Intrator is director of the Geriatrics and Extended Care Data Analysis Center (GECDAC) at the Canandaigua Veterans Affairs Medical Center (VAMC) and a professor of public health sciences at the University of Rochester, both in New York
| | - Winifred Scott
- Winifred Scott is a health science specialist at GECDAC and at the Health Economics Resource Center at the Palo Alto VAMC, in Menlo Park, California
| | - Scott T Shreve
- Scott T. Shreve is national director of hospice and palliative care at the Lebanon VAMC, in Pennsylvania
| | - Ciaran S Phibbs
- Ciaran S. Phibbs is associate director of GECDAC and a health economist at the Health Economics Resource Center at the Palo Alto VAMC and a professor of neonatology at Stanford University, both in California
| | - Bruce Kinosian
- Bruce Kinosian is associate director of GECDAC at the Center for Health Equity Research and Promotion, Philadelphia VAMC, and an associate professor of medicine at the University of Pennsylvania, in Philadelphia
| | - Richard M Allman
- Richard M. Allman is chief consultant in the Office of Geriatrics and Extended Care Services, Department of Veterans Affairs, in Washington, D.C
| | - Thomas E Edes
- Thomas E. Edes is executive director of geriatrics and extended care operations in the Office of Geriatrics and Extended Care services, Department of Veterans Affairs
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109
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Khateeb R, Puelle MR, Firn J, Saul D, Chang R, Min L. Interprofessional Rounds Improve Timing of Appropriate Palliative Care Consultation on a Hospitalist Service. Am J Med Qual 2018; 33:569-575. [PMID: 29644871 PMCID: PMC9097960 DOI: 10.1177/1062860618768069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
Despite known benefits, palliative care (PC) consultation for hospitalized patients remains underutilized. The objective was to improve frequency and timeliness of appropriate inpatient PC consultation. On 2 of 11 hospitalist teams, a PC representative attended discharge rounds twice a week. Control teams' discharge rounds were unenhanced. Subjects were all patients admitted to a hospitalist service in a quaternary academic medical center. The primary outcome was change in provision of PC consultation over time; the secondary outcome was change in time-to-consult (days). Hospitalists were surveyed regarding the intervention. The unadjusted proportion of patients receiving PC consultation increased from 2.7% to 5.2% on the intervention teams. Compared to control teams over time and adjusting for multiple covariates, the intervention increased PC consultation (difference-in-difference [DID] = 1.0 percentage-point increase [95% CI = 0.3%-1.8%]) and decreased time to consult (DID = -5 days [95% CI = -11 to -1]) in patients admitted for noncancer diagnoses. Hospitalists thought the intervention facilitated effective patient care without increased burden.
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Affiliation(s)
| | | | | | | | | | - Lillian Min
- 1 University of Michigan, Ann Arbor, MI
- 4 VA Ann Arbor Healthcare System, Ann Arbor, MI
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110
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Abstract
BACKGROUND Payment models for palliative care vary across nations, with few adopting contemporary payments designs that apply to other parts of the health system. AIM To propose optimal payment arrangements for palliative care. APPROACH Review of relevant literature on funding mechanisms in health care generally and palliative care in particular. RESULTS Payment models for palliative care should move toward activity-based funding using an agreed classification, be uncapped funding with performance monitoring, and make explicit use of performance metrics and reporting. CONCLUSIONS If palliative care is to become a universally accessible service, new approaches to funding, based on the experience of funding reforms in other parts of the health system, need to be adopted.
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Affiliation(s)
- Stephen Duckett
- Health Program, Grattan Institute, 8 Malvina Place, Carlton, VIC, 3053, Australia.
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111
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Hoerger M, Greer JA, Jackson VA, Park ER, Pirl WF, El-Jawahri A, Gallagher ER, Hagan T, Jacobsen J, Perry LM, Temel JS. Defining the Elements of Early Palliative Care That Are Associated With Patient-Reported Outcomes and the Delivery of End-of-Life Care. J Clin Oncol 2018; 36:1096-1102. [PMID: 29474102 DOI: 10.1200/jco.2017.75.6676] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose We describe the key elements of early palliative care (PC) across the illness trajectory and examine whether visit content was associated with patient-reported outcomes and end-of-life care. Methods We performed a secondary analysis of patients with newly diagnosed advanced lung or noncolorectal GI cancer (N = 171) who were randomly assigned to receive early PC. Participants attended at least monthly visits with board-certified PC physicians and advanced practice nurses at Massachusetts General Hospital. PC clinicians completed surveys documenting visit content after each encounter. Patients reported quality of life (Functional Assessment of Cancer Therapy-General) and mood (Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9) at baseline and 24 weeks. End-of-life care data were abstracted from the electronic health record. We summarized visit content over time and used linear and logistic regression to identify whether the proportion of visits addressing a content area was associated with patient-reported outcomes and end-of-life care. Results We analyzed data from 2,921 PC visits, most of which addressed coping (64.2%) and symptom management (74.5%). By 24 weeks, patients who had a higher proportion of visits that addressed coping experienced improved quality of life ( P = .02) and depression symptoms (Depression subscale of the Hospital Anxiety and Depression Scale, P = .002; Patient Health Questionnaire-9, P = .004). Patients who had a higher proportion of visits address treatment decisions were less likely to initiate chemotherapy ( P = .02) or be hospitalized ( P = .005) in the 60 days before death. Patients who had a higher proportion of visits addressing advance care planning were more likely to use hospice ( P = .03). Conclusion PC clinicians' focus on coping, treatment decisions, and advance care planning is associated with improved patient outcomes. These data define the key elements of early PC to enable dissemination of the integrated care model.
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Affiliation(s)
- Michael Hoerger
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Joseph A Greer
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Vicki A Jackson
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Elyse R Park
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - William F Pirl
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Areej El-Jawahri
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Emily R Gallagher
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Teresa Hagan
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Juliet Jacobsen
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Laura M Perry
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer S Temel
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
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112
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Gruhler H, Krutka A, Luetke-Stahlman H, Gardner E. Determining Palliative Care Penetration Rates in the Acute Care Setting. J Pain Symptom Manage 2018; 55:226-235. [PMID: 28935130 DOI: 10.1016/j.jpainsymman.2017.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 09/07/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT Intermountain Healthcare, in collaboration with Cerner Corporation, developed a hospital-based electronic palliative care algorithm. OBJECTIVES This study aims to improve identification of patients who would benefit from palliative care services, and calculate palliative care penetration rates. METHODS This study used a mixed-methods nonrandomized retrospective study design. Three 30-day iterations of clinical data were analyzed for patients identified by the electronic algorithm. During the second and third 30-day iterations, palliative care clinicians conducted chart reviews on a weekly basis for identified patients and determined whether the patients were appropriate for a palliative care consult. Positive predictive values (PPVs) were calculated. Based on the PPV, palliative care consult penetration rates were also calculated. RESULTS During the first iteration, the algorithm triggered 2995 times on 1384 unique patient encounters (69.3% of the total inpatient population). In the second iteration, the algorithm triggered 851 times on 477 unique patient encounters (26.4% of the total inpatient population). Eight hundred twenty-one chart reviews were completed on 420 unique patient encounters. The PPV was 68.3%. Based on the PPV, the projected palliative care penetration rate was 17.6%. During the third iteration, the algorithm triggered 1229 times on 539 unique patient encounters (33.3% of the total inpatient population). Nine hundred sixty-seven chart reviews were completed on 505 unique patient encounters. The PPV was 80.1%. Based on the PPV, the projected palliative care penetration rate was 26.4%. CONCLUSION This study successfully optimized an electronic palliative care identification algorithm with a PPV of 80.1% and indicates appropriate palliative care penetration rates may be as high as 26.4% of the total inpatient population.
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Affiliation(s)
| | - April Krutka
- Intermountain Healthcare, Salt Lake City, Utah, USA
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113
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Lowrie D, Ray R, Plummer D, Yau M. Exploring the Contemporary Stage and Scripts for the Enactment of Dying Roles: A Narrative Review of the Literature. OMEGA-JOURNAL OF DEATH AND DYING 2017; 76:328-350. [PMID: 29284312 DOI: 10.1177/0030222817696541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This narrative review explores the literature regarding the drama of dying from several academic perspectives. Three key themes were identified including "The impact of blurred boundaries on roles and transitions," "The orchestration of death and dying through time," and "Contemporary dying and new machinery of control." This review reveals the manner in which tightly scripted dying roles serve the needs of the living to a greater extent than those of the dying, by ensuring the depiction of both dying and death as phenomena which have been brought under the control of the living, thereby countering death anxiety. An incongruence between the actual experience of dying and contemporary dying scripts is also highlighted. The authors argue that this incongruence is hidden from the broader societal audience through the maintenance of a dying role that demands serenity and acceptance, thus downplaying or even hiding the actual end-of-life experiences of the dying themselves.
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Affiliation(s)
- Daniel Lowrie
- 1 College of Healthcare Sciences, James Cook University, Douglas, Australia
| | - Robin Ray
- 2 College of Medicine and Dentistry, James Cook University, Douglas, Australia
| | - David Plummer
- 3 College of Public Health, Medical and Veterinary Sciences, James Cook University, Douglas, Australia
| | - Matthew Yau
- 4 School of Medical & Health Sciences, Tung Wah College, Kowloon, Hong Kong
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115
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Bull J, Kamal AH, Harker M, Bonsignore L, Morris J, Massie L, Singh Bhullar P, Hendrix M, Bennett D, Taylor D. Tracking Patients in Community-Based Palliative Care through the Centers for Medicare & Medicaid Services Healthcare Innovation Project. J Palliat Med 2017; 20:1231-1236. [DOI: 10.1089/jpm.2017.0080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Janet Bull
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Arif H. Kamal
- Duke University Medical Center, Durham, North Carolina
| | | | | | - John Morris
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Lisa Massie
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | | | - Mark Hendrix
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Deeana Bennett
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Don Taylor
- Duke Sanford School of Policy, Durham, North Carolina
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Omilion-Hodges LM, Swords NM. The Grim Reaper, Hounds of Hell, and Dr. Death: The Role of Storytelling for Palliative Care in Competing Medical Meaning Systems. HEALTH COMMUNICATION 2017; 32:1272-1283. [PMID: 27668969 DOI: 10.1080/10410236.2016.1219928] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Palliative care (PC) is a medical specialty that strives to fulfill the physical, psychosocial, emotional, practical, and spiritual needs of individuals at end of life or in tandem with curative treatment. Although exponentially rising in use and beneficial to patient well-being at end of life, the purpose of PC is often misunderstood and those providing its services frequently report resistance from organizational members. Such resistance can be attributed to tensions between traditional biomedical models of medicine that privilege curative treatment and biosocial models of medicine that holistically care for patients. Thus, this study addresses what tensions PC providers experience in their institutions and what communicative strategies they use at the interpersonal level in managing those tensions. Using structuration theory in tandem with relational dialectics theory, we inductively analyzed semistructured interviews with 24 Circle of Life award-winning PC providers. Findings indicate two dialectics experienced by PC providers in their institutions: the living-dying dialectic and the practicing-advocating dialectic. We conclude that these interpersonal dialectics emerge through interaction in competing medical meaning systems and found that storytelling was a particularly salient form of communication that participants used for management.
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Affiliation(s)
| | - Nathan M Swords
- b Department of Communication Studies , University of Nebraska-Lincoln
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117
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Robinson MT, Holloway RG. Palliative Care in Neurology. Mayo Clin Proc 2017; 92:1592-1601. [PMID: 28982489 DOI: 10.1016/j.mayocp.2017.08.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 07/25/2017] [Accepted: 08/07/2017] [Indexed: 12/12/2022]
Abstract
Palliative medicine is a specialty that focuses on improving the quality of life for patients with serious or advanced medical conditions, and it is appropriate at any stage of disease, including at the time of diagnosis. Neurologic conditions tend to have high symptom burdens, variable disease courses, and poor prognoses that affect not only patients but also their families and caregivers. Patients with a variety of neurologic conditions such as Parkinson disease, dementia, amyotrophic lateral sclerosis, brain tumors, stroke, and acute neurologic illnesses have substantial unmet needs that can be addressed through a combination of primary and specialty palliative care. The complex needs of these patients are ideally managed with a comprehensive approach to care that addresses the physical, psychological, social, and spiritual aspects of care in an effort to reduce suffering. Early discussions about prognosis, goals of care, and advance care planning are critical as they can provide guidance for treatment decisions and allow patients to retain a sense of autonomy despite progressive cognitive or functional decline. With the rapid growth in palliative care across the United States, there are opportunities to improve the palliative care knowledge of neurology trainees, the delivery of palliative care to patients with neurologic disease by both neurologists and nonneurologists, and the research agenda for neuropalliative care.
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Affiliation(s)
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
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118
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How Medicine Has Changed the End of Life for Patients With Cardiovascular Disease. J Am Coll Cardiol 2017; 70:1276-1289. [DOI: 10.1016/j.jacc.2017.07.735] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/13/2017] [Accepted: 07/19/2017] [Indexed: 12/20/2022]
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119
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Bakitas MA, El-Jawahri A, Farquhar M, Ferrell B, Grudzen C, Higginson I, Temel JS, Zimmermann C, Smith TJ. The TEAM Approach to Improving Oncology Outcomes by Incorporating Palliative Care in Practice. J Oncol Pract 2017; 13:557-566. [DOI: 10.1200/jop.2017.022939] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Palliative care (PC) concurrent with usual oncology care is now the standard of care that is recommended for any patient with advanced cancer to begin within 8 weeks of diagnosis on the basis of evidence-driven national clinical practice guidelines; however, there are not enough interdisciplinary palliative care teams to provide such care. How and what can an oncology office incorporate into usual care, borrowing the tools used in PC randomized clinical trials (RCTs), to improve care for patients and their caregivers? We reviewed the multiple RCTs for common practical elements and identified methods and techniques that oncologists can use to deliver some parts of concurrent interdisciplinary PC. We recommend the standardized assessment of patient-reported outcomes, including the evaluation of symptoms with such tools as the Edmonton or Memorial Symptom Assessment Scales, spirituality with the FICA Spiritual History Tool or similar questions, and psychosocial distress with the Distress Thermometer. All patients should be assessed for how they prefer to receive information, their current understanding of their situation, and if they have considered some advance care planning. Approximately 1 hour of additional time with the patient is required each month. If the oncologist does not have established ties with spiritual care and social work, he or she should establish these relationships for counseling as required. Caregivers should be asked about coping and support needs. Oncologists can adapt PC techniques to achieve results that are similar to those in the RCTs of PC plus usual care compared with usual care alone. This is comparable to using data from RCTs of trastuzamab or placebo, adopting what was used in the RCTs without modification or dilution.
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Affiliation(s)
- Marie A. Bakitas
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Areej El-Jawahri
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Morag Farquhar
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Betty Ferrell
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Corita Grudzen
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Irene Higginson
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Jennifer S. Temel
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Camilla Zimmermann
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Thomas J. Smith
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
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120
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Pantilat SZ, Marks AK, Bischoff KE, Bragg AR, O'Riordan DL. The Palliative Care Quality Network: Improving the Quality of Caring. J Palliat Med 2017; 20:862-868. [DOI: 10.1089/jpm.2016.0514] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Steven Z. Pantilat
- Palliative Care Program, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
| | - Angela K. Marks
- Palliative Care Program, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
| | - Kara E. Bischoff
- Palliative Care Program, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
| | | | - David L. O'Riordan
- Palliative Care Program, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
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121
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Yin Z, Li J, Ma K, Ning X, Chen H, Fu H, Zhang H, Wang C, Bruera E, Hui D. Development of Palliative Care in China: A Tale of Three Cities. Oncologist 2017; 22:1362-1367. [PMID: 28739870 PMCID: PMC5679827 DOI: 10.1634/theoncologist.2017-0128] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 06/08/2017] [Indexed: 12/02/2022] Open
Abstract
Although the most populous country in the world, China has limited palliative care programs. This article presents examples of three palliative care programs in China and encourages the program development in other Chinese hospitals. Background. China is the most populous country in the world, but access to palliative care is extremely limited. A better understanding of the development of palliative care programs in China and how they overcome the barriers to provide services would inform how we can further integrate palliative care into oncology practices in China. Here, we describe the program development and infrastructure of the palliative care programs at three Chinese institutions, using these as examples to discuss strategies to accelerate palliative care access for cancer patients in China. Methods. Case study of three palliative care programs in Chengdu, Kunming, and Beijing. Results. The three examples of palliative care delivery in China ranged from a comprehensive program that includes all major branches of palliative care in Chengdu, a program that is predominantly inpatient‐based in Kunming, and a smaller program at an earlier stage of development in Beijing. Despite the numerous challenges related to the limited training opportunities, stigma on death and dying, and lack of resources and policies to support clinical practice, these programs were able to overcome many barriers to offer palliative care services to patients with advanced diseases and to advance this discipline in China through visionary leadership, collaboration with other countries to acquire palliative care expertise, committed staff members, and persistence. Conclusion. Palliative care is limited in China, although a few comprehensive programs exist. Our findings may inform palliative care program development in other Chinese hospitals. Implications for Practice. With a population of 1.3 billion, China is the most populous country in the world, and cancer is the leading cause of death. However, only 0.7% of hospitals offer palliative care services, which significantly limits palliative care access for Chinese cancer patients. Here, we describe the program development and infrastructure of three palliative care programs in China, using these as examples to discuss how they were able to overcome various barriers to implement palliative care. Lessons from these programs may help to accelerate the progress of palliative cancer care in China.
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Affiliation(s)
- Zhenyu Yin
- Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, Houston, Texas, USA
- Department of Geriatric Oncology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjng University Medical Shool, Nanjing, Jiangsu, People's Republic of China
| | - Jinxiang Li
- West China Fourth Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Ke Ma
- The Third People's Hospital of Kunming, Kunming, Yunnan, People's Republic of China
| | - Xiaohong Ning
- Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Huiping Chen
- West China Fourth Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Haiyan Fu
- The Third People's Hospital of Kunming, Kunming, Yunnan, People's Republic of China
| | - Haibo Zhang
- Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, Houston, Texas, USA
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Chun Wang
- Department of Geriatric Oncology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjng University Medical Shool, Nanjing, Jiangsu, People's Republic of China
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, Houston, Texas, USA
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122
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Kogan AC, Kobashigawa W, Taguchi J, Carter K. "Everyone Deserves to be Remembered Like This": Videotaped Autobiography and End-of-Life Discussions Among Those With Serious or Terminal Illness. J Pain Symptom Manage 2017; 54:e1-e3. [PMID: 28232216 PMCID: PMC5800756 DOI: 10.1016/j.jpainsymman.2017.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/08/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Alexis Coulourides Kogan
- Department of Family Medicine and Geriatrics, Keck School of Medicine of USC, University of Southern California, Alhambra, California, USA.
| | - Wesley Kobashigawa
- Older Adult Homebound Program, San Fernando Valley Community Mental Health Center, Van Nuys, California, USA
| | | | - Kate Carter
- LifeChronicles, Santa Barbara, California, USA
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123
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Neloska L, Damevska K, Kuzmanova A, Pavleska L, Kostov M, Zovic BP. Dermatologische Erkrankungen bei Palliativpatienten: eine prospektive Studie an 271 Patienten. J Dtsch Dermatol Ges 2017; 15:621-628. [PMID: 28591438 DOI: 10.1111/ddg.13236_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/26/2016] [Indexed: 01/25/2023]
Affiliation(s)
- Lenche Neloska
- Institut für Gerontologie "13ter November", Skopje, Republik Mazedonien
| | - Katerina Damevska
- Abteilung für Dermatologie, Medizinische Fakultät, Universität "St. Kyrill und Method", Skopje, Republik Mazedonien
| | | | - Lidija Pavleska
- Institut für Gerontologie "13ter November", Skopje, Republik Mazedonien
| | - Milenko Kostov
- Abteilung für Neurochirurgie, Medizinische Fakultät, Skopje, Republik Mazedonien
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Harrison KL, Dzeng E, Ritchie CS, Shanafelt TD, Kamal AH, Bull JH, Tilburt JC, Swetz KM. Addressing Palliative Care Clinician Burnout in Organizations: A Workforce Necessity, an Ethical Imperative. J Pain Symptom Manage 2017; 53:1091-1096. [PMID: 28196784 PMCID: PMC5474199 DOI: 10.1016/j.jpainsymman.2017.01.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 01/09/2017] [Accepted: 01/10/2017] [Indexed: 01/17/2023]
Abstract
Clinician burnout reduces the capacity for providers and health systems to deliver timely, high quality, patient-centered care and increases the risk that clinicians will leave practice. This is especially problematic in hospice and palliative care: patients are often frail, elderly, vulnerable, and complex; access to care is often outstripped by need; and demand for clinical experts will increase as palliative care further integrates into usual care. Efforts to mitigate and prevent burnout currently focus on individual clinicians. However, analysis of the problem of burnout should be expanded to include both individual- and systems-level factors as well as solutions; comprehensive interventions must address both. As a society, we hold organizations responsible for acting ethically, especially when it relates to deployment and protection of valuable and constrained resources. We should similarly hold organizations responsible for being ethical stewards of the resource of highly trained and talented clinicians through comprehensive programs to address burnout.
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Affiliation(s)
- Krista L Harrison
- Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.
| | - Elizabeth Dzeng
- Division of Hospital Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Christine S Ritchie
- Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA
| | - Tait D Shanafelt
- Hematology, School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Janet H Bull
- Four Seasons Compassion for Life, Flat Rock North Carolina, USA
| | - Jon C Tilburt
- General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Keith M Swetz
- University of Alabama - Birmingham, Birmingham, Alabama, USA; Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
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125
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Neloska L, Damevska K, Kuzmanova A, Pavleska L, Kostov M, Zovic BP. Dermatological diseases in palliative care patients: a prospective study of 271 patients. J Dtsch Dermatol Ges 2017; 15:621-627. [PMID: 28513987 DOI: 10.1111/ddg.13236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/26/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Numerous risk factors place palliative care patients at an increased risk of skin infections, dermatitis, and pressure sores. Furthermore, worsening of chronic skin disorders can be expected, as well as the development of treatment-induced and malignancy-related dermatoses. The objective of the present study was to investigate the prevalence and treatment of dermatological conditions in patients receiving hospital-based palliative care. METHODS Two hundred seventy-one palliative patients were enrolled. All assessments were conducted by dermatologists. Skin lesions were classified into seven categories: infections, skin tumors, dermatitis, chronic wounds, nail and hair disorders, pruritus, and other unclassified conditions. Treatment modalities were classified as topical only or systemic. RESULTS Overall, 1,267 dermatological conditions were recorded, 49 % of which were hospital-acquired. All patients had at least one dermatological condition, and more than 50 different dermatological disorders were noted. The most common group of skin disorders was dermatitis (18.3 % of all dermatological conditions), followed by nail and hair disorders (17.5 %). Almost 16 % of dermatological conditions were treated systemically. CONCLUSIONS Dermatological conditions are a common and clinically significant problem for palliative patients. The inclusion of dermatologists in multidisciplinary palliative teams should prove helpful in the management of these patients.
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Affiliation(s)
- Lenche Neloska
- Gerontology Institute "13 November", Skopje, Republic of Macedonia
| | - Katerina Damevska
- Department of Dermatology, Medical Faculty, University "Ss Cyrilius and Methodius", Skopje, Republic of Macedonia
| | | | - Lidija Pavleska
- Gerontology Institute "13 November", Skopje, Republic of Macedonia
| | - Milenko Kostov
- Department of Neurosurgery, Medical Faculty, Skopje, Republic of Macedonia
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126
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Lupu D, Salsberg E, Quigley L, Wu X. The 2015 Class of Hospice and Palliative Medicine Fellows-From Training to Practice: Implications for HPM Workforce Supply. J Pain Symptom Manage 2017; 53:944-951. [PMID: 28189768 DOI: 10.1016/j.jpainsymman.2017.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/28/2016] [Accepted: 01/02/2017] [Indexed: 11/20/2022]
Abstract
CONTEXT A relatively new specialty, hospice and palliative medicine (HPM), is unusual in that physicians can enter from 10 different specialties. This study sought to understand where HPM physicians were coming from, where they were going to practice, and the job market for HPM physicians. OBJECTIVES Describe characteristics of the incoming supply of HPM physicians, their practice plans, and experience finding initial jobs. METHODS In October 2015, we conducted an online survey of physicians who completed accredited HPM fellowships the previous June. We had electronic mail addresses for 195 of the 243 graduating fellows. RESULTS About 112 HPM fellows responded (58% of those invited). The most common prior training was internal medicine (45%), followed by family medicine (23%), pediatrics (12%), and emergency medicine (10%). More than 40% had practiced medicine before their HPM training. After graduation, 97% were providing 20 or more hours per week of patient care, with most hours in palliative care. About 72% devoted more than 20 hours per week to palliative care, whereas only 13% worked that much in hospice care. About 81% reported no difficulty finding a satisfactory practice position. About 98% said that they would recommend HPM to others, and 63% took the time to provide written comments that were highly positive about the specialty. CONCLUSION New HPM physicians are finding satisfying jobs. They are enthusiastic in recommending the specialty to others. Most are going into palliative medicine, leaving questions about how the need for hospice physicians will be filled. Although jobs appear to be numerous, there are practice areas with more limited opportunities.
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Affiliation(s)
- Dale Lupu
- The George Washington University School of Nursing, Washington, DC, USA; Dale View Associates, Silver Spring, Maryland, USA.
| | - Ed Salsberg
- The George Washington University School of Nursing and Health Workforce Institute, Washington, DC, USA
| | - Leo Quigley
- The George Washington University School of Nursing and Health Workforce Institute, Washington, DC, USA
| | - Xiaoli Wu
- George Washington University, Washington, DC, USA
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Building a palliative radiation oncology program: From bedside to B.E.D. Pract Radiat Oncol 2017; 7:203-208. [DOI: 10.1016/j.prro.2016.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/29/2016] [Accepted: 09/08/2016] [Indexed: 11/23/2022]
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128
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Isenberg SR, Lu C, McQuade J, Razzak R, Weir BW, Gill N, Smith TJ, Holtgrave DR. Economic Evaluation of a Hospital-Based Palliative Care Program. J Oncol Pract 2017; 13:e408-e420. [PMID: 28418761 DOI: 10.1200/jop.2016.018036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Establish costs of an inpatient palliative care unit (PCU) and conduct a threshold analysis to estimate the maximum possible costs for the PCU to be considered cost effective. METHODS We used a hospital perspective to determine costs on the basis of claims from administrative data from Johns Hopkins PCU between March 2013 and March 2014. Using existing literature, we estimated the number of quality-adjusted life years (QALYs) that the PCU could generate. We conducted a threshold analysis to assess the maximum costs for the PCU to be considered cost effective, incorporating willingness to pay ($180,000 per QALY). Three types of costs were considered, which included variable costs alone, contribution margin (ie, revenue minus variable costs), and PCU cost savings compared with usual care (from a separate publication). RESULTS The data showed that there were 153 patient encounters (PEs), variable costs of $1,050,031 ($1,343 per PE per day), a contribution margin of $318,413 ($407 per PE per day), and savings compared with usual care of $353,645 ($452 savings per PE per day). On the basis of the literature, the program could generate 3.11 QALYs from PEs (0.05 QALY) and caregivers (3.06 QALYs). The threshold analysis determined that the maximum variable cost required to be cost effective was $559,800 (an additional $716 per PE per day could be spent). CONCLUSION According to variable costs, the PCU was not cost effective; however, when considering savings of the PCU compared with usual care, the PCU was cost saving. The contribution margin showed that the PCU was cost saving. This study supports efforts to expand PCUs, which enhance care for patients and their caregivers and can generate hospital savings. Future research should prospectively explore the cost utility of PCUs.
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Affiliation(s)
- Sarina R Isenberg
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; and Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Medical Institutions, Baltimore, MD
| | - Chunhua Lu
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; and Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Medical Institutions, Baltimore, MD
| | - John McQuade
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; and Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Medical Institutions, Baltimore, MD
| | - Rab Razzak
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; and Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brian W Weir
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; and Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Medical Institutions, Baltimore, MD
| | - Natasha Gill
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; and Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Medical Institutions, Baltimore, MD
| | - Thomas J Smith
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; and Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Medical Institutions, Baltimore, MD
| | - David R Holtgrave
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; and Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Medical Institutions, Baltimore, MD
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Reid MC, Ghesquiere A, Kenien C, Capezuti E, Gardner D. Expanding palliative care's reach in the community via the elder service agency network. ANNALS OF PALLIATIVE MEDICINE 2017; 6:S104-S107. [PMID: 28595429 DOI: 10.21037/apm.2017.03.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 02/06/2017] [Indexed: 11/06/2022]
Abstract
Over the past two decades, palliative care has established itself as a promising approach to address the complex needs of individuals with advanced illness. Palliative care is well-established in US hospitals and has recently begun to expand outside of the hospital setting to meet the needs of non-hospitalized individuals. Experts have called for the development of innovative community-based models that facilitate delivery of palliative care to this target population. Elder service agencies are important partners that researchers should collaborate with to develop new and promising models. Millions of older adults receive aging network services in the U.S., highlighting the potential reach of these models. Recent health care reform efforts provide support for community-based initiatives, where coordination of care and services, delivered via health and social service agencies, is highly prioritized. This article describes the rationale for developing such approaches, including efforts to educate elder service agency clients about palliative care; training agency staff in palliative care principles; building capacity for elder services providers to screen individuals for palliative care needs; embedding palliative care "champions" in agencies to educate staff and clients and coordinate access to services among those with palliative care needs; and leveraging telehealth resources to conduct comprehensive assessments by hospital palliative care teams for elder service clients who have palliative care needs. We maintain that leveraging the resources of elder service agencies could measurably expand the reach of palliative care in the community.
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Affiliation(s)
- M Carrington Reid
- Department of Medicine, Weill Cornell Medical Center, New York, NY, USA.
| | - Angela Ghesquiere
- Brookdale Center for Healthy Aging, Hunter College of CUNY, New York, NY, USA
| | - Cara Kenien
- Department of Medicine, Weill Cornell Medical Center, New York, NY, USA
| | - Elizabeth Capezuti
- Hunter-Bellevue School of Nursing, Hunter College of CUNY, New York, NY, USA
| | - Daniel Gardner
- Brookdale Center for Healthy Aging, Hunter College of CUNY, New York, NY, USA
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130
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Rommelfanger KS, Factor SA, LaRoche S, Rosen P, Young R, Rapaport MH. Disentangling Stigma from Functional Neurological Disorders: Conference Report and Roadmap for the Future. Front Neurol 2017; 8:106. [PMID: 28424653 PMCID: PMC5372777 DOI: 10.3389/fneur.2017.00106] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/03/2017] [Indexed: 11/13/2022] Open
Abstract
A multidisciplinary expert review of key issues and future directions from the conference “Controversial labels and clinical uncertainties: psychogenic disorders, conversion disorder, and functional symptoms.” On October 9 and 10, 2015, a conference entitled “Controversial labels and clinical uncertainties: psychogenic disorders, conversion disorder, and functional symptoms” was held at the Center for Ethics, Emory University, Atlanta, GA, USA. This conference brought together a select group of 30 distinguished thought leaders and practitioners, including ethicists, researchers, clinicians, humanities scholars, and advocates to discuss the unique challenges and controversies related to the diagnosis, treatment, and stigma for patients with what is currently recognized as functional (“psychogenic”) neurological disorders. Our group of experts explored the conflicts and ethical tensions within health care that must be addressed in order to advance care for these disorders. What follows is a reflection on the conversations between conference attendees outlining key challenges and value conflicts in the diagnosis and treatment of patients with functional disorders. With this report, we aim to provide a roadmap for reducing stigma and improving care for functional neurological disorders (FND). A path forward would involve (1) setting a multifactorial research agenda that equally prioritized access to effective psychotherapy as well as identification of novel biomarkers; (2) empowering patients with FND to be heard and to drive changes in care; and (3) reducing isolation for clinicians by providing formal training and setting up multidisciplinary care teams and support networks.
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Affiliation(s)
- Karen S Rommelfanger
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA.,Department of Neurology, Emory University, Atlanta, GA, USA.,Center for Ethics Neuroethics Program, Emory University, Atlanta, GA, USA
| | | | - Suzette LaRoche
- Department of Neurology, Emory University, Atlanta, GA, USA.,Mission Health, Epilepsy Center, Asheville, NC, USA
| | - Phyllis Rosen
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA
| | - Raymond Young
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA
| | - Mark H Rapaport
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA
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Miller PR, Chang MC, Hoth JJ, Hildreth AN, Wolfe SQ, Gross JL, Martin RS, Carter JE, Meredith JW, D'Agostino R. Predicting Mortality and Independence at Discharge in the Aging Traumatic Brain Injury Population Using Data Available at Admission. J Am Coll Surg 2017; 224:680-685. [PMID: 28263858 DOI: 10.1016/j.jamcollsurg.2016.12.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/19/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Aging worsens outcome in traumatic brain injury (TBI), but available studies may not provide accurate outcomes predictions due to confounding associated injuries. Our goal was to develop a predictive tool using variables available at admission to predict outcomes related to severity of brain injury in aging patients. STUDY DESIGN Characteristics and outcomes of blunt trauma patients, aged 50 or older, with isolated TBI, in the National Trauma Data Bank (NTDB), were evaluated. Equations predicting survival and independence at discharge (IDC) were developed and validated using patients from our trauma registry, comparing predicted with actual outcomes. RESULTS Logistic regression for survival and IDC was performed in 57,588 patients using age, sex, Glasgow Coma Scale score (GCS), and Revised Trauma Score (RTS). All variables were independent predictors of outcome. Two models were developed using these data. The first included age, sex, and GCS. The second substituted RTS for GCS. C statistics from the models for survival and IDC were 0.90 and 0.82 in the GCS model. In the RTS model, C statistics were 0.80 and 0.67. The use of GCS provided better discrimination and was chosen for further examination. Using a predictive equation derived from the logistic regression model, outcome probabilities were calculated for 894 similar patients from our trauma registry (January 2012 to March 2016). The survival and IDC models both showed excellent discrimination (p < 0.0001). Survival and IDC generally decreased by decade: age 50 to 59 (80% IDC, 6.5% mortality), 60 to 69 (82% IDC, 7.0% mortality), 70 to 79 (76% IDC, 8.9% mortality), and 80 to 89 (67% IDC, 13.4% mortality). CONCLUSIONS These models can assist in predicting the probability of survival and IDC for aging patients with TBI. This provides important data for loved ones of these patients when addressing goals of care.
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Affiliation(s)
- Preston R Miller
- Department of Surgery, Wake Forest University, Winston-Salem, NC.
| | - Michael C Chang
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - J Jason Hoth
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Amy N Hildreth
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest University, Winston-Salem, NC
| | - Jessica L Gross
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - R Shayn Martin
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Jeffrey E Carter
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - J Wayne Meredith
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Ralph D'Agostino
- Wake Forest Health Science Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC
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Isenberg SR, Lu C, McQuade J, Chan KKW, Gill N, Cardamone M, Torto D, Langbaum T, Razzak R, Smith TJ. Impact of a New Palliative Care Program on Health System Finances: An Analysis of the Palliative Care Program Inpatient Unit and Consultations at Johns Hopkins Medical Institutions. J Oncol Pract 2017; 13:e421-e430. [PMID: 28245147 DOI: 10.1200/jop.2016.014860] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Palliative care inpatient units (PCUs) can improve symptoms, family perception of care, and lower per-diem costs compared with usual care. In March 2013, Johns Hopkins Medical Institutions (JHMI) added a PCU to the palliative care (PC) program. We studied the financial impact of the PC program on JHMI from March 2013 to March 2014. METHODS This study considered three components of the PC program: PCU, PC consultations, and professional fees. Using 13 months of admissions data, the team calculated the per-day variable cost pre-PCU (ie, in another hospital unit) and after transfer to the PCU. These fees were multiplied by the number of patients transferred to the PCU and by the average length of stay in the PCU. Consultation savings were estimated using established methods. Professional fees assumed a collection rate of 50%. RESULTS The total positive financial impact of the PC program was $3,488,863.17. There were 153 transfers to the PCU, 60% with cancer, and an average length of stay of 5.11 days. The daily loss pretransfer to the PCU of $1,797.67 was reduced to $1,345.34 in the PCU (-25%). The PCU saved JHMI $353,645.17 in variable costs, or $452.33 per transfer. Cost savings for PC consultations in the hospital, 60% with cancer, were estimated at $2,765,218. $370,000 was collected in professional fees savings. CONCLUSION The PCU and PC program had a favorable impact on JHMI while providing expert patient-centered care. As JHMI moves to an accountable care organization model, value-based patient-centered care and increased intensive care unit availability are desirable.
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Affiliation(s)
- Sarina R Isenberg
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; Johns Hopkins Medical Institutions, Baltimore, MD; Sunnybrook Odette Cancer Centre; University of Toronto; and Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Chunhua Lu
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; Johns Hopkins Medical Institutions, Baltimore, MD; Sunnybrook Odette Cancer Centre; University of Toronto; and Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - John McQuade
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; Johns Hopkins Medical Institutions, Baltimore, MD; Sunnybrook Odette Cancer Centre; University of Toronto; and Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; Johns Hopkins Medical Institutions, Baltimore, MD; Sunnybrook Odette Cancer Centre; University of Toronto; and Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Natasha Gill
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; Johns Hopkins Medical Institutions, Baltimore, MD; Sunnybrook Odette Cancer Centre; University of Toronto; and Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Michael Cardamone
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; Johns Hopkins Medical Institutions, Baltimore, MD; Sunnybrook Odette Cancer Centre; University of Toronto; and Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Deirdre Torto
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; Johns Hopkins Medical Institutions, Baltimore, MD; Sunnybrook Odette Cancer Centre; University of Toronto; and Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Terry Langbaum
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; Johns Hopkins Medical Institutions, Baltimore, MD; Sunnybrook Odette Cancer Centre; University of Toronto; and Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Rab Razzak
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; Johns Hopkins Medical Institutions, Baltimore, MD; Sunnybrook Odette Cancer Centre; University of Toronto; and Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Thomas J Smith
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Health System; Johns Hopkins Medical Institutions, Baltimore, MD; Sunnybrook Odette Cancer Centre; University of Toronto; and Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
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Isenberg SR, Aslakson RA, Smith TJ. Implementing Evidence-Based Palliative Care Programs and Policy for Cancer Patients: Epidemiologic and Policy Implications of the 2016 American Society of Clinical Oncology Clinical Practice Guideline Update. Epidemiol Rev 2017; 39:123-131. [PMID: 28472313 PMCID: PMC5858032 DOI: 10.1093/epirev/mxw002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2016] [Indexed: 12/25/2022] Open
Abstract
The American Society of Clinical Oncology (ASCO) recently convened an Ad Hoc Palliative Care Expert Panel to update a 2012 provisional clinical opinion by conducting a systematic review of clinical trials in palliative care in oncology. The key takeaways from the updated ASCO clinical practice guidelines (CPGs) are that more people should be referred to interdisciplinary palliative care teams and that more palliative care specialists and palliative care-trained oncologists are needed to meet this demand. The following summary statement is based on multiple randomized clinical trials: "Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs" (J Clin Oncol. 2017;35(1):96). This paper addresses potential epidemiologic and policy interpretations and implications of the ASCO CPGs. Our review of the CPGs demonstrates that to have clinicians implement these guidelines, there is a need for support from stakeholders across the health-care continuum, health system and institutional change, and changes in health-care financing. Because of rising costs and the need to improve value, the need for coordinated care, and change in end-of-life care patterns, many of these changes are already underway.
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Affiliation(s)
- Sarina R Isenberg
- Department of Health, Behavior, and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rebecca A Aslakson
- Department of Health, Behavior, and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Acute and Chronic Care, The Johns Hopkins School of Nursing, Baltimore, Maryland
- Departments of Oncology and Medicine and the Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Comprehensive Cancer Center, The Johns Hopkins Hospital, Baltimore, Maryland
- the Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland
| | - Thomas J Smith
- Departments of Oncology and Medicine and the Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Shalev D, Brewster K, Arbuckle MR, Levenson JA. A staggered edge: End-of-life care in patients with severe mental illness. Gen Hosp Psychiatry 2017; 44:1-3. [PMID: 28041569 PMCID: PMC5849470 DOI: 10.1016/j.genhosppsych.2016.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 10/15/2016] [Accepted: 10/18/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Daniel Shalev
- New York State Psychiatric Institute/Columbia University Department of Psychiatry, 1051 Riverside Drive, Box 103, New York, NY 10032, United States.
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Ferrell BR, Temel JS, Temin S, Alesi ER, Balboni TA, Basch EM, Firn JI, Paice JA, Peppercorn JM, Phillips T, Stovall EL, Zimmermann C, Smith TJ. Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2016; 35:96-112. [PMID: 28034065 DOI: 10.1200/jco.2016.70.1474] [Citation(s) in RCA: 1245] [Impact Index Per Article: 155.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose To provide evidence-based recommendations to oncology clinicians, patients, family and friend caregivers, and palliative care specialists to update the 2012 American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) on the integration of palliative care into standard oncology care for all patients diagnosed with cancer. Methods ASCO convened an Expert Panel of members of the ASCO Ad Hoc Palliative Care Expert Panel to develop an update. The 2012 PCO was based on a review of a randomized controlled trial (RCT) by the National Cancer Institute Physicians Data Query and additional trials. The panel conducted an updated systematic review seeking randomized clinical trials, systematic reviews, and meta-analyses, as well as secondary analyses of RCTs in the 2012 PCO, published from March 2010 to January 2016. Results The guideline update reflects changes in evidence since the previous guideline. Nine RCTs, one quasiexperimental trial, and five secondary analyses from RCTs in the 2012 PCO on providing palliative care services to patients with cancer and/or their caregivers, including family caregivers, were found to inform the update. Recommendations Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs. Providers may refer family and friend caregivers of patients with early or advanced cancer to palliative care services.
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Affiliation(s)
- Betty R Ferrell
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jennifer S Temel
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Sarah Temin
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Erin R Alesi
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Tracy A Balboni
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ethan M Basch
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Janice I Firn
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Judith A Paice
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jeffrey M Peppercorn
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Tanyanika Phillips
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ellen L Stovall
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Thomas J Smith
- Betty R. Ferrell, City of Hope Medical Center, Duarte, CA; Jennifer S. Temel and Jeffrey M. Peppercorn, Massachusetts General Hospital; Tracy A. Balboni, Dana-Farber Cancer Institute, Boston, MA; Sarah Temin, American Society of Clinical Oncology, Alexandria; Erin R. Alesi, Virginia Commonwealth University Health System, Richmond, VA; Ethan M. Basch, University of North Carolina at Chapel Hill, Chapel Hill, NC; Janice I. Firn, University of Michigan Health System, Ann Arbor, MI; Judith A. Paice, Northwestern University, Evanston, IL; Tanyanika Phillips, CHRISTUS St Frances Cabrini Hospital, Alexandria, LA; Ellen L. Stovall, National Coalition for Cancer Survivorship, Silver Spring; Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and Camilla Zimmermann, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Bakitas MA, Elk R, Astin M, Ceronsky L, Clifford KN, Dionne-Odom JN, Emanuel LL, Fink RM, Kvale E, Levkoff S, Ritchie C, Smith T. Systematic Review of Palliative Care in the Rural Setting. Cancer Control 2016; 22:450-64. [PMID: 26678972 DOI: 10.1177/107327481502200411] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Many of the world's population live in rural areas. However, access and dissemination of the advances taking place in the field of palliative care to patients living in rural areas have been limited. METHODS We searched 2 large databases of the medical literature and found 248 relevant articles; we also identified another 59 articles through networking and a hand search of reference lists. Of those 307 articles, 39 met the inclusion criteria and were grouped into the following subcategories: intervention (n = 4), needs assessment (n = 2), program planning (n = 3), program evaluation (n = 4), education (n = 7), financial (n = 8), and comprehensive/systematic literature reviews (n = 11). RESULTS We synthesized the current state of rural palliative care research and practice to identify important gaps for future research. Studies were conducted in the United States, Australia, Canada, Africa, Sweden, and India. Two randomized control trials were identified, both of which used telehealth approaches and had positive survival outcomes. One study demonstrated positive patient quality of life and depression outcomes. CONCLUSIONS Research to guide rural palliative care practice is sparse. Approaches to telehealth, community- academic partnerships, and training rural health care professionals show promise, but more research is needed to determine best practices for providing palliative care to patients living in rural settings.
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Affiliation(s)
- Marie A Bakitas
- School of Nursing, Center for Palliative and Supportive Care, University of Alabama at Birmingham, AL.
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137
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Rocker G, Downar J, Morrison RS. Palliative care for chronic illness: driving change. CMAJ 2016; 188:E493-E498. [PMID: 27551031 DOI: 10.1503/cmaj.151454] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Graeme Rocker
- Department of Medicine (Rocker), Dalhousie University, Halifax, NS; Division of Respirology (Rocker), QEII Health Sciences Centre, Halifax, NS; Palliative Care and Critical Care (Downar), University Health Network, Toronto, Ont.; Divisions of Critical Care and Palliative Care (Downar), University of Toronto, Toronto, Ont.; National Palliative Care Research Center (Morrison), New York, NY; Hertzberg Palliative Care Institute (Morrison), Mt. Sinai School of Medicine, New York, NY; Brookdale Department of Geriatrics and Palliative Medicine (Morrison), Icahn School of Medicine at Mount Sinai, New York, NY
| | - James Downar
- Department of Medicine (Rocker), Dalhousie University, Halifax, NS; Division of Respirology (Rocker), QEII Health Sciences Centre, Halifax, NS; Palliative Care and Critical Care (Downar), University Health Network, Toronto, Ont.; Divisions of Critical Care and Palliative Care (Downar), University of Toronto, Toronto, Ont.; National Palliative Care Research Center (Morrison), New York, NY; Hertzberg Palliative Care Institute (Morrison), Mt. Sinai School of Medicine, New York, NY; Brookdale Department of Geriatrics and Palliative Medicine (Morrison), Icahn School of Medicine at Mount Sinai, New York, NY
| | - R Sean Morrison
- Department of Medicine (Rocker), Dalhousie University, Halifax, NS; Division of Respirology (Rocker), QEII Health Sciences Centre, Halifax, NS; Palliative Care and Critical Care (Downar), University Health Network, Toronto, Ont.; Divisions of Critical Care and Palliative Care (Downar), University of Toronto, Toronto, Ont.; National Palliative Care Research Center (Morrison), New York, NY; Hertzberg Palliative Care Institute (Morrison), Mt. Sinai School of Medicine, New York, NY; Brookdale Department of Geriatrics and Palliative Medicine (Morrison), Icahn School of Medicine at Mount Sinai, New York, NY
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138
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Abstract
Palliative care services are becoming more prevalent in the United States as greater portions of the population are requiring end-of-life services. Furthermore, recent policy changes and service foci have promoted more continuity and encompassing care. This study evaluates characteristics that distinguish hospitals with a palliative care program from hospitals without such a program in order to better define the markets and environments that promote the creation and usage of these programs. This study demonstrates that palliative care programs are more likely in communities with favorable economic factors and higher Medicare populations. Large hospitals with high occupancy rates and a high case mix index use palliative care programs to better meet patient needs and improve hospital efficiency. Managerial, nursing, and policy implications are discussed relating to further usage and implementation of palliative care programs.
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139
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Okafor PN, Stobaugh DJ, Nnadi AK, Talwalkar JA. Determinants of Palliative Care Utilization Among Patients Hospitalized With Metastatic Gastrointestinal Malignancies. Am J Hosp Palliat Care 2016; 34:269-274. [DOI: 10.1177/1049909115624373] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Gastrointestinal tract cancers account for a significant proportion of the national cancer burden. Aim: We sought to explore patient- and hospital-level determinants of palliative care utilization among patients hospitalized with metastatic gastrointestinal tract cancers using a national database. Methods: An analysis of the 2012 National Inpatient Sample was performed. International Classification of Diseases, Ninth Revision codes were used to identify hospital discharges associated with metastatic digestive tract cancers and patient/hospital covariates for inclusion in a logistic regression model. Total charges and length of stay were analyzed in a linear regression model. Results: Compared to males, females were more likely to receive inpatient palliative care (adjusted odds ratio [OR] 1.12, P = .002). No difference was seen between white and Asian patients (adjusted OR 1.2, P = .11) or Native Americans patients (adjusted OR 1.4, P = .22). However, relative to white patients, African Americans (adjusted OR 1.13, P = .02) and Hispanics (adjusted OR 1.25, P = .001) had significantly higher odds of inpatient palliative care. Medicare patients were least likely to receive palliative care compared to those with Medicaid or commercial payers. Length of stay during these hospitalizations was longer in African Americans ( P = .0001), Asians ( P = .0001), and Native Americans ( P = .03) compared to white patients. No difference was seen when total charges were compared between white and African American patients ( P = .08). Conversely, total charges were higher in Hispanics ( P = .005) and Asians ( P = .001) relative to white patients. Conclusion: Gender and racial differences exist in utilization of inpatient palliative care among patients hospitalized with metastatic gastrointestinal tract cancers.
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Affiliation(s)
- Philip N. Okafor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Jayant A. Talwalkar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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140
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Golden AG, Antoni C, Gammonley D. A Home-Based Palliative Care Consult Service for Veterans. Am J Hosp Palliat Care 2016. [DOI: 10.1177/1049909115595497] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We describe the development and implementation of a home-based palliative care consult service for Veterans with advanced illness. A retrospective chart review was performed on 73 Veterans who received a home-based palliative care consult. Nearly one-third were 80 years of age or older, and nearly one-third had a palliative diagnosis of cancer. The most common interventions of the consult team included discussion of advance directives, completion of a “do not resuscitate” form, reduction/stoppage of at least 1 medication, explanation of diagnosis, referral to home-based primary care program, referral to hospice, and assessment/support for caregiver stress. The home-based consult service was therefore able to address clinical and psychosocial issues that can demonstrate a direct benefit to Veterans, families, and referring clinicians.
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Affiliation(s)
- Adam G. Golden
- University of Central Florida College of Medicine, Orlando, FL, USA
- Orlando Veterans Affairs Medical Center, Orlando, FL, USA
| | - Charles Antoni
- Orlando Veterans Affairs Medical Center, Orlando, FL, USA
| | - Denise Gammonley
- University of Central Florida, College of Health and Public Affairs, Orlando, FL, USA
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141
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Harrison KL, Connor SR. First Medicare Demonstration of Concurrent Provision of Curative and Hospice Services for End-of-Life Care. Am J Public Health 2016; 106:1405-8. [PMID: 27310352 DOI: 10.2105/ajph.2016.303238] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Hospice developed in the United States in the 1970s as a way to address unmet needs for end-of-life care: support for pain and symptom management provided in the location and manner that the patient and family prefer. In Europe and Australia, hospice is available from the time of diagnosis of an advanced life-limiting illness onward, but in the United States, the Medicare hospice benefit restricts eligibility for these services to patients who no longer receive curative treatment. We provide background and analysis of the first Medicare hospice demonstration in 35 years that will test the concurrent provision of curative and hospice services for terminally ill individuals with a life expectancy of six months or less. This demonstration is a harbinger of potential policy changes to hospice and palliative care in the United States that could reduce barriers to end-of-life care that aligns with patient and family preferences as the demand for care increases with an aging population.
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Affiliation(s)
- Krista L Harrison
- Krista L. Harrison is with the Division of Geriatrics at University of California, San Francisco. Stephen R. Connor is with Worldwide Hospice Palliative Care Alliance, Fairfax Station, VA
| | - Stephen R Connor
- Krista L. Harrison is with the Division of Geriatrics at University of California, San Francisco. Stephen R. Connor is with Worldwide Hospice Palliative Care Alliance, Fairfax Station, VA
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142
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Van Hoover C, Holt L. Midwifing the End of Life: Expanding the Scope of Modern Midwifery Practice to Reclaim Palliative Care. J Midwifery Womens Health 2016; 61:306-14. [PMID: 27148997 DOI: 10.1111/jmwh.12454] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 01/17/2016] [Accepted: 01/21/2016] [Indexed: 11/27/2022]
Abstract
Historically, midwives held an important role in society as cradle-to-grave practitioners who eased individuals, families, and communities through difficult transitions across the life span. In the United States, during the first half of the 20th century, physicians assumed care for people during birth and death, moving these elements of the human experience from homes into the hospital setting. These changes in practice resulted in a dehumanization of birth and death experiences and led to detachment from what it means to be human among members of society. There is a current movement across the United States to incorporate palliative care and hospice care into both the home setting and the inpatient setting. Through their education and training, certified nurse-midwives/certified midwives (CNMs/CMs) are well equipped to serve as hospice and palliative care clinicians. Current midwives, skilled in assisting women and families through the transition of pregnancy to motherhood, can use their education and skills to help individuals and their families through the transition from life to death. The similarities between these states of the human experience (pregnancy to birth and terminal illness to death) allow for a fluidity between these experiences from the midwife perspective. The many parallels between these 2 elements of the human condition include stress, anxiety, and pain. Training in holistic approaches to symptom management and supporting individuals through difficult experiences (eg, birth) gives midwives a unique perspective that is readily translatable to assist individuals and families through the passage between life and death.
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143
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Wong A, Reddy A, Williams JL, Wu J, Liu D, Bruera E, Wong A, Reddy A, Williams JL, Wu J, Liu D, Bruera E. ReCAP: Attitudes, Beliefs, and Awareness of Graduate Medical Education Trainees Regarding Palliative Care at a Comprehensive Cancer Center. J Oncol Pract 2016; 12:149-50; e127-37. [PMID: 26787756 PMCID: PMC5702790 DOI: 10.1200/jop.2015.006619] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Palliative care (PC) training and integration with oncology care remain suboptimal. Current attitudes and beliefs of the oncology trainees regarding PC are not fully known. This study was undertaken in an attempt to address this issue. PARTICIPANTS AND METHODS We conducted a survey to determine awareness of PC among graduate medical trainees at a comprehensive cancer center with an established PC program. One hundred seventy oncology trainees who completed$9 months of training in medical, surgical, gynecologic, and radiation oncology fellowships and residency programs during the 2013 academic year completed an online questionnaire. Descriptive, univariable, and multivariable analyses were performed. RESULTS The response rate was 78% (132 of 170 trainees); 10 trainees without hands-on patient care were excluded. Medical (53 of 60 [88%]), gynecologic (six of six [100%]), and radiation oncology (20 of 20 [100%]) trainees reported more awareness of PC compared with surgical oncology (22 of 36 [61%]) trainees (P = .001). One hundred twelve of 122 (92%) perceived PC as beneficial to patients and families. One hundred eight of 122 (89%) perceived that PC can reduce health care costs, 78 (64%) believed that PC can increase survival, and 90 (74%) would consult PC for a patient with newly diagnosed cancer with symptoms. Eighty-two trainees (67%) believed a mandatory PC rotation is important. Trainees with previous exposure to PC rotations were more aware of the role of PC services than were trainees without PC rotation (96% [46 of 48] v 74% [55 of 74]; P = .005, respectively). CONCLUSION Surgical trainees and trainees without previous PC rotation had significantly less awareness of PC. Overall, trainees perceived PC as beneficial to patients and capable of reducing costs while increasing survival; they also supported early PC referrals and endorsed a mandatory PC rotation.
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Affiliation(s)
| | - Akhila Reddy
- The University of Texas MD Anderson Cancer Center
| | | | - Jimin Wu
- The University of Texas MD Anderson Cancer Center
| | - Diane Liu
- The University of Texas MD Anderson Cancer Center
| | | | - Angelique Wong
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Akhila Reddy
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Jimin Wu
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Diane Liu
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston, TX.
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144
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Portman D, Thirlwell S. Perspectives, Progress, and Opportunities for Palliative Care in Oncology. Cancer Control 2015; 22:382-4. [PMID: 26678964 DOI: 10.1177/107327481502200402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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145
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Rocker GM, Simpson AC, Horton R. Palliative Care in Advanced Lung Disease: The Challenge of Integrating Palliation Into Everyday Care. Chest 2015; 148:801-809. [PMID: 25742140 DOI: 10.1378/chest.14-2593] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The tendency toward "either/or" thinking (either cure or comfort) in traditional biomedical care paradigms does little to optimize care in advancing chronic illness. Calls for improved palliation in chronic lung disease mandate a review of related care gaps and current clinical practices. Although specialist palliative services have their advocates, adding yet another element to an already fragmented, often complex, care paradigm can be a challenge. Instead, we propose a more holistic, patient-centered approach based on elements fundamental to palliative and best care practices generally and integrated as needed across the entire illness trajectory. To support this approach, we review the concept of primary palliative care competencies, identify vulnerability specific to those living with advanced COPD (an exemplar of chronic lung disease), and describe the need for care plans shaped by patient-centered communication, timely palliative responsiveness, and effective advance care planning. A costly systemic issue in the management of chronic lung disease is patients' increasing dependency on episodic ED care to deal with preventable episodic crises and refractory dyspnea. We address this issue as part of a proposed model of care that provides proactive, collaborative case management and the appropriate and carefully monitored use of opioids. We encourage and support a renewed primary care resolve to integrate palliative approaches to care in advanced lung disease that, in concert with judicious referral to appropriate specialist palliative care services, is fundamental to what should be a more sustainable systematic improvement in palliative care delivery.
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Affiliation(s)
| | - A Catherine Simpson
- Implementing a Novel and Supportive Program of Individualized Care for Patients and Families Living With Respiratory Disease (INSPIRED) COPD Outreach Program, Halifax, NS, Canada
| | - Robert Horton
- Division of Palliative Medicine, Capital Health Integrated Palliative Care, Halifax, NS, Canada
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146
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Rahimzadeh V, Bartlett G, Longo C, Crimi L, Macdonald ME, Jabado N, Ells C. Promoting an ethic of engagement in pediatric palliative care research. BMC Palliat Care 2015; 14:50. [PMID: 26474573 PMCID: PMC4608148 DOI: 10.1186/s12904-015-0048-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 10/08/2015] [Indexed: 11/12/2022] Open
Abstract
Background This paper defends the ethical and empirical significance of direct engagement with terminally ill children and adolescents in PPC research on health-related quality of life. Clinical trials and other forms of health research have resulted in tremendous progress for improving clinical outcomes among children and adolescents diagnosed with a life-threatening illness. Less attention has been paid, however, to engaging this patient population directly in studies aimed at optimizing health-related quality of life in PPC. Though not restricted to care at the end of life, PPC—and by extension PPC research—is in part dependent on recognizing the social complexities of death and dying and where health-related quality of life is a fundamental element. To explore these complexities in depth requires partnership with terminally ill children and adolescents, and acknowledgement of their active social and moral agency in research. Discussion Principles of pediatric research ethics, theoretical tenets of the “new sociology of the child(hood),” and human rights codified in the United Nations Convention on the Rights of the Child (UNCRC) underpin the position that a more engagement-centered approach is needed in PPC research. The ethics, sociologies and human rights of engagement will each be discussed as they relate to research with terminally ill children and adolescents in PPC. Qualitative method(ologies) presented in this paper, such as deliberative stakeholder consultations and phenomenology of practice can serve as meaningful vehicles for achieving i) participation among terminally ill children and adolescents; ii) evidence-bases for PPC best practices; and iii) fulfillment of research ethics principles. Conclusion PPC research based on direct engagement with PPC patients better reflects their unique expertise and social epistemologies of terminal illness. Such an approach to research would strengthen both the ethical and methodological soundness of HRQoL inquiry in PPC.
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Affiliation(s)
- Vasiliki Rahimzadeh
- Department of Family Medicine, Centre of Genomics and Policy, McGill University, 5858 Côte-des-Neiges, Suite 300, Montréal, QC, H3S 1Z1, Canada.
| | - Gillian Bartlett
- Department of Family Medicine, McGill University, 5858 Côte-des-Neiges, Suite 300, Montréal, QC, H3S 1Z1, Canada
| | - Cristina Longo
- Department of Family Medicine, McGill University, 5858 Côte-des-Neiges, Suite 300, Montréal, QC, H3S 1Z1, Canada
| | - Laura Crimi
- Department of Family Medicine, McGill University, 5858 Côte-des-Neiges, Suite 300, Montréal, QC, H3S 1Z1, Canada
| | - Mary Ellen Macdonald
- Division of Oral Health and Society, Pediatric Palliative Care Research, Montreal Children's Hospital, McGill University, #530-2001 McGill College Avenue, Montreal, QC, H3A 1G1, Canada
| | - Nada Jabado
- Department of Pediatrics, Montreal Children's Hospital Research Institute, McGill University Health Center, 1001 Décarie Boulevard, Montreal, H4A 3J1, QC, Canada
| | - Carolyn Ells
- Biomedical Ethics Unit, McGill University, 3647 Peel St, Montreal, QC, H3A 1X1, Canada
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147
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Omilion-Hodges LM, Swords NM. Communication that heals: mindful communication practices from palliative care leaders. HEALTH COMMUNICATION 2015; 31:328-335. [PMID: 26360619 DOI: 10.1080/10410236.2014.953739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Though research has begun to highlight the centrality of communication in palliative care, studies have yet to focus on the use of mindful communication. Mindful communication is associated with increases in patient care and decreases in physician burnout. Through in-depth, semi-structured interviews the authors sought mindful communication practices from palliative care leaders in American Hospital Association Circle of Life® award-wining units. Four key mindful communication practices emerged: Know your audience, ask questions, discard scripts, and recognize your role. The discussion articulates how key mindful communication practices may be used as a stage model, where key practices may be used individually or in concert, by sole practitioners or within interdisciplinary teams and by new and seasoned clinicians. Theoretical contributions and areas for future inquiry are also discussed.
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Affiliation(s)
| | - Nathan M Swords
- b Department of Communication Studies University of Nebraska-Lincoln
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148
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Hebert R, Argo Ben Itzhak N. A Potential Downside to Promoting the Economic Benefits of Palliative Medicine. J Palliat Med 2015; 18:738. [DOI: 10.1089/jpm.2015.0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Randy Hebert
- Palliative Medicine and Hospice, Allegheny Health Network, Pittsburgh, Pennsylvania
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149
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Abstract
OBJECTIVES To describe palliative care as part of comprehensive oncology nursing care. DATA SOURCES A review of the palliative care, oncology, and nursing literature over the past 10 years. CONCLUSION Palliative care is mandated as part of comprehensive cancer care. A cancer diagnosis often results in distress in the physical, psychosocial, spiritual, and emotional domains of care. Oncology nurses are essential in providing palliative care from diagnosis to death to patients with cancer. They address the myriad aspects of cancer. With palliative care skills and knowledge, oncology nurses can provide quality cancer care. There are many opportunities in which oncology nurses can promote palliative care. IMPLICATIONS FOR NURSING PRACTICE Oncology nurses must obtain knowledge and skills in primary palliative care to provide comprehensive cancer care.
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150
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Integration of Palliative Care Services in the Intensive Care Unit: A Roadmap for Overcoming Barriers. Clin Chest Med 2015; 36:441-8. [PMID: 26304281 DOI: 10.1016/j.ccm.2015.05.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Clinicians working in the intensive care unit (ICU) confront death and dying daily. ICU care can be inconsistent with a patient's values, preferences, and previously expressed goals of care. Current evidence promotes the integration of palliative care services within the ICU setting. Palliative care bridges the gap between comfort and cure, and these services are growing in the United States. This article discusses the benefits and barriers to integration of ICU and palliative care services, and a stepwise approach to implementation of palliative care services. Integration of palliative care services into ICU workflow is increasingly seen as essential to providing high-quality, comprehensive critical care.
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