101
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Henson LA, Gao W, Higginson IJ, Smith M, Davies JM, Ellis-Smith C, Daveson BA. Emergency department attendance by patients with cancer in their last month of life: a systematic review and meta-analysis. J Clin Oncol 2014; 33:370-6. [PMID: 25534384 DOI: 10.1200/jco.2014.57.3568] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To explore factors associated with emergency department (ED) attendance by patients with cancer in their last month of life. METHODS Five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Library) were searched through February 2014 for studies investigating ED attendance toward the end of life by adult patients (age 18 years or older) with cancer. No time or language limitations were applied. We performed meta-analysis of factors using a random-effects model, with results expressed as odds ratios (OR) for ED attendance. Sensitivity analyses explored heterogeneity. RESULTS Thirty studies were identified, reporting three demographic, five clinical, and 13 environmental factors, combining data from five countries and 1,181,842 patients. An increased likelihood of ED attendance was found for men (OR, 1.24; 95% CI, 1.19 to 1.29; I(2), 58.2%), black race (OR, 1.45; 95% CI, 1.40 to 1.50; I(2), 0.0%; reference, white race), patients with lung cancer (OR, 1.17; 95% CI, 1.10 to 1.23; I(2), 59.5%; reference, other cancers), and those patients of the lowest socioeconomic status (SES; OR, 1.15; 95% CI, 1.10 to 1.19; I(2), 0.0%; reference, highest SES). Patients receiving palliative care were less likely to attend the ED in their last month of life (OR, 0.43; 95% CI, 0.36 to 0.51; I(2), 59.4%). CONCLUSION We identified demographic (men; black race), clinical (lung cancer), and environmental (low SES; no palliative care) factors associated with an increased risk of ED attendance by patients with cancer in their last month of life. Our findings may be used to develop screening interventions and assist policy-makers to direct resources. Future studies should also investigate previously neglected areas of research, including psychosocial factors, and patients' and caregivers' emergency care preferences.
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Affiliation(s)
- Lesley A Henson
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom.
| | - Wei Gao
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Irene J Higginson
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Melinda Smith
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Joanna M Davies
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Clare Ellis-Smith
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Barbara A Daveson
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
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Fernandes S, Guthrie DM. A Comparison Between End-of-Life Home Care Clients With Cancer and Heart Failure in Ontario. Home Health Care Serv Q 2014; 34:14-29. [DOI: 10.1080/01621424.2014.995257] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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103
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Langton JM, Blanch B, Drew AK, Haas M, Ingham JM, Pearson SA. Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: a systematic review. Palliat Med 2014; 28:1167-96. [PMID: 24866758 DOI: 10.1177/0269216314533813] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND There has been an increase in observational studies using health administrative data to examine the nature, quality, and costs of care at life's end, particularly in cancer care. AIM To synthesize retrospective observational studies on resource utilization and/or costs at the end of life in cancer patients. We also examine the methods and outcomes of studies assessing the quality of end-of-life care. DESIGN A systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) methodology. DATA SOURCES We searched MEDLINE, Embase, CINAHL, and York Centre for Research and Dissemination (1990-2011). Independent reviewers screened abstracts of 14,424 articles, and 835 full-text manuscripts were further reviewed. Inclusion criteria were English-language; at least one resource utilization or cost outcome in adult cancer decedents with solid tumors; outcomes derived from health administrative data; and an exclusive end-of-life focus. RESULTS We reviewed 78 studies examining end-of-life care in over 3.7 million cancer decedents; 33 were published since 2008. We observed exponential increases in service use and costs as death approached; hospital services being the main cost driver. Palliative services were relatively underutilized and associated with lower expenditures than hospital-based care. The 15 studies using quality indicators demonstrated that up to 38% of patients receive chemotherapy or life-sustaining treatments in the last month of life and up to 66% do not receive hospice/palliative services. CONCLUSION Observational studies using health administrative data have the potential to drive evidence-based palliative care practice and policy. Further development of quality care markers will enhance benchmarking activities across health care jurisdictions, providers, and patient populations.
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Affiliation(s)
- Julia M Langton
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Bianca Blanch
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Anna K Drew
- Prince of Wales Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia
| | - Marion Haas
- Centre for Health Economics Research and Evaluation, The University of Technology Sydney, Sydney, NSW, Australia
| | - Jane M Ingham
- Cunningham Centre for Palliative Care, Sacred Heart Health Service, NSW, Australia St Vincents' Hospital Clinical School, Faculty of Medicine, The University of New South Wales, NSW, Australia
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Sezgin Goksu S, Gunduz S, Unal D, Uysal M, Arslan D, Tatlı AM, Bozcuk H, Ozdogan M, Coskun HS. Use of chemotherapy at the end of life in Turkey. BMC Palliat Care 2014; 13:51. [PMID: 25435808 PMCID: PMC4247666 DOI: 10.1186/1472-684x-13-51] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 11/10/2014] [Indexed: 12/18/2022] Open
Abstract
Background An increasing number of patients receive palliative chemotherapy near the end of life. The aim of this study is to evaluate the aggressiveness of chemotherapy in Turkish individuals near the end of life. Methods Patients diagnosed with solid tumors and died from 2010 to 2011 in the medical oncology department of Akdeniz University were included in the study. Data about the diagnosis, treatment details and imaging procedures were collected. Results Three hundred and seventy-three people with stage IV solid tumors died from 2010 to 2011 in our clinic. Eighty-nine patients (23.9%) patients underwent chemotherapy in the last month of life while 39 patients (10.5%) received chemotherapy in the last 14 days. The probability of undergoing chemotherapy in the last month of life was influenced by: age, ‘newly diagnosed’ patients, and performance status. There was no significant association of chemotherapy in the last month of life with gender and tumor type. Having a PET-CT scan did not alter the chemotherapy decision. Conclusion In conclusion, chemotherapy used in the last month of life in a tertiary care center of Turkey is high. Increasing quality of life should be a priority near the end of life and physicians should consider ceasing chemotherapy and direct the patient to early palliative care.
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Affiliation(s)
- Sema Sezgin Goksu
- Department of Medical Oncology, Kayseri State Hospital of Research and Education, Kayseri, Turkey
| | - Seyda Gunduz
- Department of Medical Oncology, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Dilek Unal
- Department of Radiation Oncology, Kayseri State Hospital of Research and Education, Kayseri, Turkey
| | - Mukremin Uysal
- Department of Medical Oncology, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Deniz Arslan
- Department of Medical Oncology, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Ali M Tatlı
- Department of Medical Oncology, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Hakan Bozcuk
- Department of Medical Oncology, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Mustafa Ozdogan
- Department of Medical Oncology, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Hasan S Coskun
- Department of Medical Oncology, Akdeniz University, Faculty of Medicine, Antalya, Turkey
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Salam-White L, Hirdes JP, Poss JW, Blums J. Predictors of emergency room visits or acute hospital admissions prior to death among hospice palliative care clients in Ontario: a retrospective cohort study. BMC Palliat Care 2014; 13:35. [PMID: 25053920 PMCID: PMC4106206 DOI: 10.1186/1472-684x-13-35] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 07/03/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hospice palliative care (HPC) is a philosophy of care that aims to relieve suffering and improve the quality of life for clients with life-threatening illnesses or end of life issues. The goals of HPC are not only to ameliorate clients' symptoms but also to reduce unneeded or unwanted medical interventions such as emergency room visits or hospitalizations (ERVH). Hospitals are considered a setting ill-prepared for end of life issues; therefore, use of such acute care services has to be considered an indicator of poor quality end of life care. This study examines predictors of ERVH prior to death among HPC home care clients. METHODS A retrospective cohort study of a sample of 764 HPC home care clients who received services from a community care access centre (CCAC) in southern Ontario, Canada. All clients were assessed using the Resident Assessment Instrument for Palliative Care (interRAI PC) as part of normal clinical practice between April 2008 and July 2010. The Andersen-Newman framework for health service utilization was used as a conceptual model for the basis of this study. Logistic regression and Cox regression analyses were carried out to identify predictors of ERVH. RESULTS Half of the HPC clients had at least one or more ERVH (n = 399, 52.2%). Wish to die at home (OR = 0.54) and advanced care directives (OR = 0.39) were protective against ERVH. Unstable health (OR = 0.70) was also associated with reduced probability, while infections such as prior urinary tract infections (OR = 2.54) increased the likelihood of ERVH. Clients with increased use of formal services had reduced probability of ERVH (OR = 0.55). CONCLUSIONS Findings of this study suggest that predisposing characteristics are nearly as important as need variables in determining ERVH among HPC clients, which challenges the assumption that need variables are the most important determinants of ERVH. Ongoing assessment of HPC clients is essential in reducing ERVH, as reassessments at specified intervals will allow care and service plans to be adjusted with clients' changing health needs and end of life preferences.
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Affiliation(s)
- Lialoma Salam-White
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Ontario N2L 3G1, Canada ; Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC), 211 Prichard Road, Unit 1, Hamilton, Ontario L8J 0G5, Canada
| | - John P Hirdes
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Ontario N2L 3G1, Canada
| | - Jeffrey W Poss
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Ontario N2L 3G1, Canada ; Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC), 211 Prichard Road, Unit 1, Hamilton, Ontario L8J 0G5, Canada
| | - Jane Blums
- Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC), 211 Prichard Road, Unit 1, Hamilton, Ontario L8J 0G5, Canada
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106
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Adam H, Hug S, Bosshard G. Chemotherapy near the end of life: a retrospective single-centre analysis of patients' charts. BMC Palliat Care 2014; 13:26. [PMID: 24917696 PMCID: PMC4051375 DOI: 10.1186/1472-684x-13-26] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 04/04/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chemotherapy near the end of life is an issue frequently discussed nowadays. The concern is that chemotherapy could cause more harm than good in a palliative situation; this is even truer as the patient nears death. The objective of our study is to evaluate the aggressiveness of patient care near the end of life by determining how many cancer patients receive chemotherapy during their final weeks. METHODS In a retrospective analysis of patient charts, we investigated whether cancer patients had been treated with chemotherapy during the last four or two weeks of life. If they had, we looked at whether treatment was ongoing or newly initiated. RESULTS Out of the 119 cancer patients who died in our hospital over two years, 14 (11.7%) received chemotherapy during the last four weeks of life, nine of whom (7.6%) in the last two weeks of life. Treatment had been ongoing in six (5%) and newly initiated for eight (6.7%) within four weeks of death. Corresponding figures for the last two weeks of life were seven patients (5.9%) who continued previously prescribed treatment and two (1.7%) who were started on chemotherapy. Patients given chemotherapy during the last four weeks of life were significantly younger than those who were not (p = 0.003). CONCLUSIONS Cancer patient care in our hospital is not considered overly aggressive as only 7.6% of these patients receive chemotherapy within the last two weeks of life. To determine how aggressive care near the end of life really is, however, we suggest evaluating newly started chemotherapy alongside ongoing treatment. As the line between the effects (beneficience) and side effects (nonmaleficience) of chemotherapy is often very narrow, doctors and patients have to work together to find the best way of treading this fine line.
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Affiliation(s)
- Hanny Adam
- Department of Oncology, City Hospital Waid, Tiechestrasse 99, CH-8037 Zurich, Switzerland
| | - Sonja Hug
- Institute for Social Work and Health, University of Applied Sciences and Arts, Northwestern Switzerland FHNW, CH-4600 Olten, Switzerland
| | - Georg Bosshard
- Geriatrics Clinic, Zurich University Hospital, and Center for Age and Mobility, University of Zurich and City Hospital Waid, Rämistrasse 100, CH-8091 Zurich, Switzerland
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107
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Marck CH, Weil J, Lane H, Weiland TJ, Philip J, Boughey M, Jelinek GA. Care of the dying cancer patient in the emergency department: findings from a National survey of Australian emergency department clinicians. Intern Med J 2014; 44:362-8. [DOI: 10.1111/imj.12379] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 02/10/2014] [Indexed: 11/29/2022]
Affiliation(s)
- C. H. Marck
- Emergency Practice Innovation Centre (EPIcentre); St Vincent's Hospital Melbourne; Melbourne Victoria Australia
| | - J. Weil
- Department of Palliative Care; St Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Centre for Palliative Care; The University of Melbourne (St Vincent's Hospital); Melbourne Victoria Australia
| | - H. Lane
- Department of Palliative Care; St Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Centre for Palliative Care; The University of Melbourne (St Vincent's Hospital); Melbourne Victoria Australia
| | - T. J. Weiland
- Emergency Practice Innovation Centre (EPIcentre); St Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Department of Medicine; The University of Melbourne (St Vincent's Hospital); Melbourne Victoria Australia
| | - J. Philip
- Department of Palliative Care; St Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Centre for Palliative Care; The University of Melbourne (St Vincent's Hospital); Melbourne Victoria Australia
| | - M. Boughey
- Department of Palliative Care; St Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Centre for Palliative Care; The University of Melbourne (St Vincent's Hospital); Melbourne Victoria Australia
| | - G. A. Jelinek
- Emergency Practice Innovation Centre (EPIcentre); St Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Department of Medicine; The University of Melbourne (St Vincent's Hospital); Melbourne Victoria Australia
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108
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Hu W, Yasui Y, White J, Winget M. Aggressiveness of end-of-life care for patients with colorectal cancer in Alberta, Canada: 2006-2009. J Pain Symptom Manage 2014; 47:231-44. [PMID: 23870414 DOI: 10.1016/j.jpainsymman.2013.03.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 03/14/2013] [Accepted: 03/29/2013] [Indexed: 11/24/2022]
Abstract
CONTEXT North American studies have documented practice variations and deficiencies in end-of-life (EOL) cancer care, such as trends toward treating dying patients aggressively and disparities in access to palliative care or hospice services. OBJECTIVES To assess the frequency of aggressive health care usage at the EOL and identify factors associated with receiving aggressive care among patients who died of colorectal cancer. METHODS Data from the Alberta Cancer Registry, in/outpatient hospital records, and cancer electronic medical records were linked. Death in an acute care hospital, chemotherapy use in the last 14 days of life, more than one emergency room (ER) visit, more than one hospital admission, and any intensive care unit (ICU) admission in the last 30 days of life were used as indicators of aggressive care. Logistic regression was used to identify risk factors associated with each indicator. RESULTS A total of 2074 patients were included: 50.1% died in an acute care hospital; 3.7% received chemotherapy in the last 14 days of life; and 12.5% had multiple ER visits, 9.5% had multiple hospitalizations, and 2.2% had an ICU admission during the last 30 days of life. Age had the strongest association with chemotherapy use. Geographical region of residence had the strongest association with multiple ER visits and hospitalizations and dying in an acute care hospital. Tumor stage and duration of disease were associated with the ICU admission. CONCLUSION The percentage of patients who died in an acute care hospital is higher than the 17% U.S. benchmark. Other indicators of receiving aggressive EOL care are consistent with existing care quality benchmarks. The considerable regional variation, however, indicates potential for system improvements.
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Affiliation(s)
- Weihong Hu
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Yutaka Yasui
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan White
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Marcy Winget
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Cancer Care, Alberta Health Services, Edmonton, Alberta, Canada.
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Almaawiy U, Pond GR, Sussman J, Brazil K, Seow H. Are family physician visits and continuity of care associated with acute care use at end-of-life? A population-based cohort study of homecare cancer patients. Palliat Med 2014; 28:176-83. [PMID: 23779252 DOI: 10.1177/0269216313493125] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous end-of-life cancer research has shown an association between increased family physician continuity of care and reduced use of acute care services; however, it did not focus on a homecare population or control for homecare nursing. AIM Among end-of-life homecare cancer patients, to investigate the association of family physician continuity with location of death and hospital and emergency department visits in the last 2 weeks of life while controlling for nursing hours. DESIGN Retrospective population-based cohort study. SETTING/PARTICIPANTS Cancer patients with ≥ 1 family physician visit in 2006 from Ontario, Canada. Family physician continuity of care was assessed using two measures: Modified Usual Provider of Care score and visits/week. Its association with location of death and hospital and emergency department visits in the last 2 weeks of life was examined using logistic regression. RESULTS Of 9467 patients identified, the Modified Usual Provider of Care score demonstrated a dose-response relationship with increasing continuity associated with decreased odds of hospital death and visiting the hospital and emergency department in the last 2 weeks of life. More family physician visits/week were associated with lower odds of an emergency department visit in the last 2 weeks of life and hospital death, except for patients with greater than 4 visits/week, where they had increased odds of hospitalizations and hospital deaths. CONCLUSIONS These results demonstrate an association between increased family physician continuity of care and decreased odds of several acute care outcomes in late life, controlling for homecare nursing and other covariates.
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110
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Tang ST, Liu TW, Chow JM, Chiu CF, Hsieh RK, Chen CH, Liu LN, Feng WL. Associations between accurate prognostic understanding and end-of-life care preferences and its correlates among Taiwanese terminally ill cancer patients surveyed in 2011-2012. Psychooncology 2014; 23:780-7. [DOI: 10.1002/pon.3482] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 12/15/2013] [Accepted: 12/17/2013] [Indexed: 01/03/2023]
Affiliation(s)
- Siew Tzuh Tang
- School of Nursing; Chang Gung University; Tao-Yuan Taiwan
| | - Tsang-Wu Liu
- National Health Research Institutes; National Institute of Cancer Research; Taipei Taiwan
| | - Jyh-Ming Chow
- Section of Hematology and Medical Oncology; Wan-Fang Hospital; Taipei Taiwan
| | - Chang-Fang Chiu
- Division of Hematology-Oncology and Comprehensive Cancer Center; China Medical University Hospital; Taichung Taiwan
| | - Ruey-Kuen Hsieh
- Division of Hematology and Oncology, Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
| | - Chen H. Chen
- School of Nursing; Kang-Ning Junior College of Medical Care and Management; Taipei Taiwan
| | - Li Ni Liu
- Department of Nursing; Fu Jen Catholic University; Taipei Taiwan
| | - Wei-Lien Feng
- National Health Research Institutes; National Institute of Cancer Research; Taipei Taiwan
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111
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Lung cancer patients frequently visit the emergency room for cancer-related and -unrelated issues. Mol Clin Oncol 2014; 2:322-326. [PMID: 24649355 DOI: 10.3892/mco.2014.241] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 01/09/2014] [Indexed: 11/05/2022] Open
Abstract
Lung cancer patients visit the emergency room (ER) for cancer-related and -unrelated reasons more often compared to patients with other types of cancer. This results in increased admissions and deaths in the ER. In this study, we retrospectively reviewed the characteristics of lung cancer patients visiting the ER in order to optimize the utilization of emergency medical services and improve the patients' quality of life. Lung cancer patients visiting the ER of a single institution over a 2-year period (2010-2011) were analyzed. The patients' chief complaints and diagnoses at presentation in the ER were classified as cancer-related and -unrelated. Hospital admission, discharge from the ER, hospital mortality and survival of advanced lung cancer patients hospitalized through admission to the ER was surveyed. A total of 113 patients visited the ER 143 times. Seventy visits (49.0%) were cancer-related and 73 (51.0%) were cancer-unrelated. Respiratory symptoms, pain, gastrointestinal and neurological events and fever were the most common cancer-related issues recorded. With the progression of cancer stage, the number of ER visits, admissions, ambulance use and hospital mortalities increased. In visits due to cancer-unrelated issues, including infection, cardiovascular and gastrointestinal diseases, fever was the most common complaint. Emergency admissions of advanced-stage patients for cancer-related issues revealed a significantly shorter median survival time compared to that for patients admitted for cancer-unrelated issues (61 vs. 406 days, respectively; P<0.05). It was observed that outpatients with lung cancer visited the ER for cancer-related and -unrelated reasons with a similar frequency. Therefore, accurate differential diagnosis in the ER is crucial for patients with lung cancer.
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112
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Healthcare Utilization by Patients Whose Care is Managed by a Primary Palliative Care Clinic. J Hosp Palliat Nurs 2013; 15. [PMID: 24363610 DOI: 10.1097/njh.0b013e3182a02b9d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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113
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Zdenkowski N, Cavenagh J, Ku YC, Bisquera A, Bonaventura A. Administration of chemotherapy with palliative intent in the last 30 days of life: the balance between palliation and chemotherapy. Intern Med J 2013; 43:1191-8. [DOI: 10.1111/imj.12245] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 07/05/2013] [Indexed: 11/27/2022]
Affiliation(s)
- N. Zdenkowski
- Department of Medical Oncology; Mercy Hospice; Calvary Mater Newcastle; Newcastle New South Wales Australia
- Hunter Cancer Research Alliance; Hunter Medical Research Institute; Newcastle New South Wales Australia
| | - J. Cavenagh
- Department of Palliative Care; Mercy Hospice; Calvary Mater Newcastle; Newcastle New South Wales Australia
- Hunter Cancer Research Alliance; Hunter Medical Research Institute; Newcastle New South Wales Australia
| | - Y. C. Ku
- Hunter Cancer Research Alliance; Hunter Medical Research Institute; Newcastle New South Wales Australia
- Clinical Systems Team; Information Technology and Telecommunication Department; Hunter New England Local Health District; Newcastle New South Wales Australia
| | - A. Bisquera
- Hunter Cancer Research Alliance; Hunter Medical Research Institute; Newcastle New South Wales Australia
- Clinical Research Design, IT and Statistical Support; Hunter Medical Research Institute; Newcastle New South Wales Australia
| | - A. Bonaventura
- Department of Medical Oncology; Mercy Hospice; Calvary Mater Newcastle; Newcastle New South Wales Australia
- Hunter Cancer Research Alliance; Hunter Medical Research Institute; Newcastle New South Wales Australia
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114
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Patel A, Dunmore-Griffith J, Lutz S, Johnstone PAS. Radiation therapy in the last month of life. Rep Pract Oncol Radiother 2013; 19:191-4. [PMID: 24936336 DOI: 10.1016/j.rpor.2013.09.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 08/23/2013] [Accepted: 09/23/2013] [Indexed: 12/25/2022] Open
Abstract
AIM We sought to survey a large, multi-center patient sample to better characterize/quantify RT utilization at the end of life. BACKGROUND Few objective data exist for radiation therapy (RT) delivery at end of life (EOL). MATERIALS AND METHODS Data were retrieved for all patients receiving RT in calendar year 2010 in the Department of Radiation Oncology at Indiana University (IU) and Howard University (HU) hospitals. Specific attention was made of the group of patients receiving RT in the last 30 days of life. RESULTS A total of 852 patients received all or part of their RT during 2010 (HU: 139, IU: 713). At time of analysis in early 2012, 179 patients had died (21%). Fifty-four patients (6.3% of total; 30% of expired patients) died within 30 days of receiving their last treatment. Twenty patients (2.3% of total; 11.2% of expired patients) received RT within their last week of life. For both sites, the median time until death from completion of therapy was 12.5 days (range 2-30 days). CONCLUSIONS Radiation in the last month of life is likely to provide minimal palliation or survival benefit. This, coupled with the financial implications, time investment, and physical costs, suggests that physicians and patients should more strongly consider hospice, and minimize duration of palliative RT courses as far as possible. As with chemotherapy, RT utilization at EOL should be considered for collection as an overuse metric.
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Affiliation(s)
- Anand Patel
- Department of Radiation Oncology, Howard University Hospital, Washington, DC 20001, United States
| | | | - Stephen Lutz
- Department of Radiation Oncology, Blanchard Valley Health System, Findlay, OH 45840, United States
| | - Peter A S Johnstone
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
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Chavoshi N, Miller T, Siden H. Resource Utilization among Individuals Dying of Pediatric Life-Threatening Diseases. J Palliat Med 2013; 16:1210-4. [DOI: 10.1089/jpm.2013.0110] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Negar Chavoshi
- University of British Columbia, Vancouver, British Columbia
- Canuck Place Children's Hospice, Vancouver, British Columbia
| | - Tanice Miller
- Canuck Place Children's Hospice, Vancouver, British Columbia
| | - Harold Siden
- University of British Columbia, Vancouver, British Columbia
- Canuck Place Children's Hospice, Vancouver, British Columbia
- British Columbia Children's Hospital, Vancouver, British Columbia
- Child and Family Research Institute, Vancouver, British Columbia
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Timing of code status documentation and end-of-life outcomes in patients admitted to an oncology ward. Support Care Cancer 2013; 22:375-81. [DOI: 10.1007/s00520-013-1983-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 09/11/2013] [Indexed: 12/21/2022]
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117
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Seow H, Bainbridge D, Bryant D. Palliative care programs for patients with breast cancer: the benefits of home-based care. BREAST CANCER MANAGEMENT 2013. [DOI: 10.2217/bmt.13.39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
SUMMARY Improving breast cancer care means enhancing end-of-life care with specialized palliative care services. Palliative care embodies a holistic approach to care that focuses on symptom management of individuals with incurable diseases, whereas end-of-life care specifically focuses on a period of time, such as the last 6 months of life, where a rapid state of decline is often evident. The purpose of this article is to explore the benefits and limitations of end-of-life care provided in the hospital and community settings, with an emphasis on the benefits of home-based care. A key strength of home-based palliative care is the ability to expand the reach of palliative care to more cancer patients beyond residential hospice or hospital settings, which are limited in bed availability. The essential features of quality end-of-life services, regardless of setting, are care that offers seamless transitions, around-the-clock access to the same providers and an interdisciplinary, whole-person approach.
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Affiliation(s)
- Hsien Seow
- Escarpment Cancer Research Institute, Hamilton, ON, Canada
| | - Daryl Bainbridge
- Department of Oncology, McMaster University, 699 Concession St, 4th Floor, Room 4-229, Hamilton, ON L8V 5C2, Canada
| | - Deanna Bryant
- Department of Oncology, McMaster University, 699 Concession St, 4th Floor, Room 4-229, Hamilton, ON L8V 5C2, Canada
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118
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Wild C, Patera N. Measuring quality in cancer care: overview of initiatives in selected countries. Eur J Cancer Care (Engl) 2013; 22:773-81. [DOI: 10.1111/ecc.12089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2013] [Indexed: 11/30/2022]
Affiliation(s)
- C. Wild
- Ludwig Boltzmann Institute for Health Technology Assessment; Vienna Austria
| | - N. Patera
- Ludwig Boltzmann Institute for Health Technology Assessment; Vienna Austria
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119
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Latent class analysis identifies three subtypes of aggressive end-of-life care: a population-based study in Taiwan. Eur J Cancer 2013; 49:3284-91. [PMID: 23756054 DOI: 10.1016/j.ejca.2013.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 05/05/2013] [Accepted: 05/10/2013] [Indexed: 11/23/2022]
Abstract
The aggressiveness of end-of-life (EOL) cancer care has often been analysed by the occurrence of several indicators, separately or aggregately. Whether aggressive EOL cancer care has different subtypes is unknown. This study sought to identify distinct subtypes of aggressive EOL care based on usage patterns of aggressive EOL-care indicators and to explore demographic, disease and treatment factors associated with the identified subtypes. This retrospective study linked data from 2001 to 2006 from three Taiwanese databases: National Registration of Death Database, Cancer Registration System and National Health Insurance claims database. Adult cancer patients (N=203,642) who died in 2001-2006 were selected. For these cancer patients' last month of life, we analysed eight indicators of aggressive EOL care: receiving chemotherapy, >1 emergency room visit, >1 hospitalisation, hospitalisation for >14 days, intensive care unit admission, received cardiopulmonary resuscitation, received intubation and received mechanical ventilation. Subtypes of aggressive EOL care were identified by latent class analysis. Among the study population, only 22.3% were treated by medical oncologists. Based on their profiles of EOL care, deceased cancer patients were classified into three subgroups: 'not aggressive' (45%), 'intent to sustain life' (33%) and 'symptom crisis' group (22%). Patients assigned to the 'intent to sustain life' group were less likely to have metastatic disease and to receive hospice care in the last year of life, but more likely to be cared for by non-medical oncologists, to die within 2 months after diagnosis and to die in hospital. EOL cancer care may be improved by understanding factors related to different subtypes of aggressive EOL care.
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120
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Do Patient-Reported Symptoms Predict Emergency Department Visits in Cancer Patients? A Population-Based Analysis. Ann Emerg Med 2013; 61:427-437.e5. [DOI: 10.1016/j.annemergmed.2012.10.010] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 10/02/2012] [Accepted: 10/05/2012] [Indexed: 11/18/2022]
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121
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Young J, Waugh L, McPhillips G, Levack P, Thompson A. Palliative care for patients with gastrointestinal cancer dying under surgical care: A case for acute palliative care units? Surgeon 2013; 11:72-5. [DOI: 10.1016/j.surge.2012.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Revised: 07/11/2012] [Accepted: 07/13/2012] [Indexed: 11/29/2022]
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122
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Palliative medicine and geriatric emergency care: challenges, opportunities, and basic principles. Clin Geriatr Med 2013. [PMID: 23177598 DOI: 10.1016/j.cger.2012.09.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients with serious or life-threatening illness are likely to find themselves in an emergency department at some point along their trajectory of illness, and they should expect to receive high-quality palliative care in that setting. Recently, emergency medicine has increasingly taken a central role in the early implementation of palliative care. This article presents an overview of palliative care in the emergency department and describes commonly encountered palliative emergencies, strategies for acute symptom management, communication strategies, and issues related to optimal use of hospice service in the emergency department.
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123
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Wiese CH, Lassen CL, Bartels UE, Taghavi M, Elhabash S, Graf BM, Hanekop GG. International recommendations for outpatient palliative care and prehospital palliative emergencies - a prospective questionnaire-based investigation. BMC Palliat Care 2013; 12:10. [PMID: 23432905 PMCID: PMC3602669 DOI: 10.1186/1472-684x-12-10] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 02/19/2013] [Indexed: 11/10/2022] Open
Abstract
Background To determine the international recommendations and current practices for the treatment and prevention of palliative emergencies. The primary goal of the study was to gather information from experts on their nationally practised concepts. Methods One hundred and fifty self-report surveys were distributed by email to selected leading experts (palliative and emergency medical care) in Europe, North and South America, Africa, Asia, and Australia. An expert in this context was defined as an author of an article that was ranked by three reviewers as relevant to outpatient palliative and emergency medical . Results The total response rate was 61% (n = 92 experts). Survey responses were obtained from 35 different countries. The following standards in the treatment of palliative emergencies were recommended: (1) early integration of “Palliative Care Teams” (PCTs) and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, drug boxes, and “Do not attempt resuscitation” orders and (4) emergency medical training (physicians and paramedics). Conclusions This study detected structurally and nationally differences in outpatient palliative care regarding the treatment of palliative emergencies. Accordingly, these differences should be discussed and adapted to the respective specifications of individual single countries. A single established outpatient palliative emergency medical care concept may be the basis for an overall out-of-hospital palliative care system.
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Affiliation(s)
- Christoph Hr Wiese
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg 93053, Germany.
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124
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Kao SC, van Zandwijk N, Corte P, Clarke C, Clarke S, Vardy J. Use of cancer therapy at the end of life in patients with malignant pleural mesothelioma. Support Care Cancer 2013; 21:1879-84. [PMID: 23408016 DOI: 10.1007/s00520-013-1753-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 02/04/2013] [Indexed: 12/29/2022]
Abstract
PURPOSE Malignant pleural mesothelioma (MPM) is considered a treatment-resistant disease. We determined the proportion of patients who received treatment in the last month of life and potential factors associated with use of chemotherapy at the end of life. METHODS Consenting MPM patients compensated by the Dust Diseases Board (DDB) were included. Patient, treatment and outcome details were obtained through the DDB, treating physicians and Medicare Australia. The association between potential factors (age, gender, geographical location, disease stage, histological subtype, palliative care referral, length of first line chemotherapy and lines of treatment) and chemotherapy use in the last month of life was determined. RESULTS A total of 147 MPM patients were included in the analysis: 78 received chemotherapy, 50 had radiotherapy and 116 had surgery (77 received more than one treatment modality whilst 56 received one treatment modality). Twenty-one patients received treatment in their last month of life: nine received chemotherapy; six, radiotherapy and six had surgery. Those who were treated with second or subsequent lines of chemotherapy were more at risk of receiving chemotherapy until the end of life (six of 19 patients, i.e., 32 %) compared to those who were only treated with first-line therapy (three of 59 patients, i.e., 5 %; p < 0.01). Patients who received chemotherapy at the end of life had shorter survival compared to those who did not receive chemotherapy at the end of life (5.3 vs. 12.5 months, respectively; p = 0.01). CONCLUSIONS Chemotherapy utilisation in the last month of life is not uncommon in this series of MPM patients. Patients who failed previous chemotherapy were more likely to receive chemotherapy near the end of life. More careful consideration of when to cease chemotherapy needs to be made as patients who received chemotherapy at the end of life had poorer survival outcome.
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Affiliation(s)
- Steven C Kao
- Asbestos Diseases Research Institute, Rhodes, Australia
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125
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Análisis de la evolución de pacientes en probable situación de últimos días en un servicio de Urgencias. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medipa.2012.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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126
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Morishima T, Lee J, Otsubo T, Ikai H, Imanaka Y. Impact of hospital case volume on quality of end-of-life care in terminal cancer patients. J Palliat Med 2012; 16:173-8. [PMID: 23140184 DOI: 10.1089/jpm.2012.0361] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Quality of end-of-life (EOL) care is gaining increasing attention. However, the relationship between hospital case volume and performance of benchmark quality indicators is not well characterized. The aim of this study was to determine whether hospital case volume affects EOL care for terminal cancer patients. METHODS We conducted a retrospective cross-sectional study using claims data of patients who died of cancer at acute-care hospitals in Kyoto prefecture, Japan, between March 2009 and May 2010. Hospitals were grouped into tertiles based on the number of terminal cancer cases. We used multilevel logistic regression models to examine the association of the following quality indicators with the tertiles: opioid use during the last 2 months of life (indicating good quality of care), provision of intensive care unit (ICU) service or life-sustaining treatments during the last month of life (poor quality), and chemotherapy during the last month of life (poor quality). RESULTS The final sample for analysis consisted of 3294 decedents from 88 hospitals. Significant associations between hospital case volume and quality of EOL care were identified after adjusting for patient and hospital characteristics. Small- and medium-volume hospitals were found to be less likely to administer opioids, and medium-volume hospitals were more likely to provide ICU service or life-sustaining treatments when compared with large-volume hospitals. No significant association between chemotherapy use and case volume was observed. CONCLUSIONS The results showed that the case volume of terminally ill cancer patients was associated with several aspects of quality of EOL care.
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Affiliation(s)
- Toshitaka Morishima
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Japan
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127
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Toole M, Lutz S, Johnstone PAS. Radiation oncology quality: aggressiveness of cancer care near the end of life. J Am Coll Radiol 2012; 9:199-202. [PMID: 22386167 DOI: 10.1016/j.jacr.2011.11.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 11/07/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE Quality in cancer care is an issue that has come to the forefront over the past decade. Although the American Society of Clinical Oncology has developed extensive quality metrics and goals, such as limiting chemotherapy being provided within the last 14 days of a patient's life, there are no similar quality metrics, and few data, in the field of radiation oncology. METHODS In this study, morbidity and mortality records from 2008 to 2011 were reviewed for patients at Indiana University who received radiation therapy (RT) within 30 days of death; 63 patients met those criteria. RESULTS Analysis showed that 22.2% of patients had Karnofsky Performance Status Scale scores >80, whereas 66.7% of patients had scores < 60. Just over half of patients (52%) were still on treatment at death, and more than half of patients (54%) had completed less than half of their original RT plans. Six patients had their final treatments on the days of their deaths, and another 43 patients had their last treatments within 10 days of death. Forty-eight percent of patients received RT for less than one-fifth of their final month of life and 21% for more than half of their last month alive. CONCLUSIONS These data are valuable in ongoing discussions of RT use at the end of life, especially as related to hospice underutilization.
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Affiliation(s)
- Michael Toole
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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128
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Sussman J, Barbera L, Bainbridge D, Howell D, Yang J, Husain A, Librach SL, Viola R, Walker H. Health system characteristics of quality care delivery: a comparative case study examination of palliative care for cancer patients in four regions in Ontario, Canada. Palliat Med 2012; 26:322-35. [PMID: 21831915 DOI: 10.1177/0269216311416697] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A number of palliative care delivery models have been proposed to address the structural and process gaps in this care. However, the specific elements required to form competent systems are often vaguely described. AIM The purpose of this study was to explore whether a set of modifiable health system factors could be identified that are associated with population palliative care outcomes, including less acute care use and more home deaths. DESIGN A comparative case study evaluation was conducted of 'palliative care' in four health regions in Ontario, Canada. Regions were selected as exemplars of high and low acute care utilization patterns, representing both urban and rural settings. A theory-based approach to data collection was taken using the System Competency Model, comprised of structural features known to be essential indicators of palliative care system performance. Key informants in each region completed study instruments. Data were summarized using qualitative techniques and an exploratory factor pattern analysis was completed. RESULTS 43 participants (10+ from each region) were recruited, representing clinical and administrative perspectives. Pattern analysis revealed six factors that discriminated between regions: overall palliative care planning and needs assessment; a common chart; standardized patient assessments; 24/7 palliative care team access; advanced practice nursing presence; and designated roles for the provision of palliative care services. CONCLUSIONS The four palliative care regional 'systems' examined using our model were found to be in different stages of development. This research further informs health system planners on important features to incorporate into evolving palliative care systems.
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Affiliation(s)
- Jonathan Sussman
- Supportive Cancer Care Research Unit, Juravinski Cancer Centre, Canada.
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129
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Liu TW, Chang WC, Wang HM, Chen JS, Koong SL, Hsiao SC, Tang ST. Use of chemotherapy at the end of life among Taiwanese cancer decedents, 2001-2006. Acta Oncol 2012; 51:505-11. [PMID: 22283469 DOI: 10.3109/0284186x.2011.653440] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The availability of new chemotherapeutic agents has lengthened the treatment timeline for advanced cancers and increases the likelihood of receiving chemotherapy near death. Use of chemotherapy near the end of life may not benefit cancer patients. However, no population-based study has examined the determinants for continuing chemotherapy at the end of life for all ages and cancer groups as well as for a whole country. This population-based study assessed the association between continuation of chemotherapy in the last month of life and patient demographics, disease characteristics, primary physician's specialty, hospital characteristics, and healthcare resource availability at the hospital and regional levels. MATERIALS AND METHODS Retrospective population-based cohort study using administrative data among 204 850 Taiwanese cancer decedents in 2001-2006. RESULTS Rates of continued chemotherapy in the last month of life for each study year were 17.5%, 17.4%, 17.3%, 19.0%, 20.0%, and 21.0%, respectively and have remained steady since 2001. Taiwanese cancer patients had greater odds for continuation of chemotherapy in the last month of life if they were male [adjusted odds ratio (AOR) 1.19, 95% confidence interval (CI) 1.13-1.25], younger, single [1.21 (1.09-1.35)], had lower comorbidity levels, were diagnosed with hematologic malignancies [1.90 (1.09-1.35)] and breast cancer [1.24 (1.08-1.43)], had metastatic disease [1.36 (1.27-1.46)], and survived < 1 year but longer than two months post-diagnosis. The odds for continued chemotherapy in patients' last month was significantly increased by being cared for by a medical oncologist [3.49 (3.04-3.99)] or in a teaching hospital [1.39 (1.11-1.74)] and with the highest intensity of total inpatient hospital beds [1.63 (0.99-2.68)], but was not influenced by regional healthcare resources (total hospital and hospice beds). CONCLUSION The relative risk for continuation of chemotherapy in the last month of life was determined by patient demographics and disease characteristics, physician specialty, and healthcare resources at the primary hospital level.
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Affiliation(s)
- Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Zhunan, Taiwan
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130
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Gilbert JE, Howell D, King S, Sawka C, Hughes E, Angus H, Dudgeon D. Quality improvement in cancer symptom assessment and control: the Provincial Palliative Care Integration Project (PPCIP). J Pain Symptom Manage 2012; 43:663-78. [PMID: 22464352 DOI: 10.1016/j.jpainsymman.2011.04.028] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 04/26/2011] [Accepted: 05/05/2011] [Indexed: 10/28/2022]
Abstract
CONTEXT The Provincial Palliative Care Integration Project (PPCIP) was implemented in Ontario, Canada, to enhance the quality of palliative care delivery. The PPCIP promoted collaboration and integration across service sectors to improve screening and assessment, palliative care processes, as well as clinician practice and outcomes for cancer patients. OBJECTIVES The project involved 1) implementation of the Edmonton Symptom Assessment System (ESAS) for symptom screening, 2) use of "rapid-cycle change" quality improvement processes to improve screening and symptom management, and 3) improvements in integration and access to palliative care services. METHODS Symptom scores were collected and made accessible to the care team through a web-based tool and kiosk technology, which helped patients enter their ESAS scores at each visit to the regional cancer center or at home with their nurse. Symptom response data were gathered through clinical chart audits. RESULTS Within one year of implementation, regional cancer centers saw improvements in symptom screening (54% of lung cancer patients), symptom control (69% of patients with pain scores and 31% of patients with dyspnea scores seven or more were reduced to six or less within 72 hours), and functional assessment (23% of all patients and 64% of palliative care clinic patients). ESAS screening rates reached 29%, and functional assessment reached 26% of targeted home care patients. CONCLUSION The PPCIP demonstrated that significant strides in symptom screening and response can be achieved within a year using rapid-cycle change and collaborative approaches. It showed that both short- and long-term improvement require ongoing facilitation to embed the changes in system design and change the culture of clinical practice.
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Affiliation(s)
- Julie E Gilbert
- Policy Research & Analysis, Cancer Care Ontario, Toronto, Ontario, Canada.
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131
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Kapadia NS, Mamet R, Zornosa C, Niland JC, D'Amico TA, Hayman JA. Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer. Cancer 2012; 118:4339-45. [PMID: 22252390 DOI: 10.1002/cncr.27401] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 12/03/2011] [Accepted: 12/09/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Receipt of chemotherapy at the end of life (EOL) is considered an indicator of poor quality of care for medical oncology. The objective of this study was to characterize the use of radiotherapy (RT) in patients with nonsmall cell lung cancer (NSCLC) during the same period. METHODS Treatment characteristics of patients with incurable NSCLC who received RT at the EOL, defined as within 14 days of death, were analyzed from the National Comprehensive Cancer Network NSCLC Outcomes Database. RESULTS Among 1098 patients who died, 10% had received EOL RT. Patients who did and did not receive EOL RT were similar in terms of sex, race, comorbid disease, and Eastern Cooperative Oncology Group performance status. On multivariable logistic regression analysis, independent predictors of receiving EOL RT included stage IV disease (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.09-3.83) or multiorgan involvement (OR, 1.75; 95% CI, 1.08-2.84) at diagnosis, age <65 years at diagnosis (OR, 1.85; 95% CI, 1.21-2.83), and treating institution (OR, 1.24-5.94; P = .02). Nearly 50% of EOL RT recipients did not complete it, most commonly because of death or patient preference. CONCLUSIONS In general, EOL RT was received infrequently, was delivered more commonly to younger patients with more advanced disease, and often was not completed as planned. There also was considerable variation in its use among National Comprehensive Cancer Network institutions. Next steps include expanding this research to other cancers and settings and investigating the clinical benefit of such treatment.
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Affiliation(s)
- Nirav S Kapadia
- Department of Radiation Oncology, University of Michigan Hospital, Ann Arbor, Michigan, USA
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132
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OLDEN T, SCHOLS J, HAMERS J, VAN DE SCHANS S, COEBERGH J, JANSSEN-HEIJNEN M. Predicting the need for end-of-life care for elderly cancer patients: findings from a Dutch regional cancer registry database. Eur J Cancer Care (Engl) 2011; 21:477-84. [DOI: 10.1111/j.1365-2354.2011.01319.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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133
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Mayer DK, Travers D, Wyss A, Leak A, Waller A. Why do patients with cancer visit emergency departments? Results of a 2008 population study in North Carolina. J Clin Oncol 2011; 29:2683-8. [PMID: 21606431 PMCID: PMC3139372 DOI: 10.1200/jco.2010.34.2816] [Citation(s) in RCA: 267] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 04/04/2011] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Emergency departments (EDs) in the United States are used by patients with cancer for disease or treatment-related problems and unrelated issues. The North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) collects information about ED visits through a statewide database. PATIENTS AND METHODS After approval by the institutional review board, 2008 NC DETECT ED visit data were acquired and cancer-related visits were identified. Descriptive statistics and logistic regressions were performed. Of 4,190,911 ED visits in 2008, there were 37,760 ED visits by 27,644 patients with cancer. RESULTS Among patients, 77.2% had only one ED visit in 2008, the mean age was 64 years, and there were slightly more men than women. Among visits, the payor was Medicare for 52.4% and Medicaid for 12.1%. More than half the visits by patients with cancer occurred on weekends or evenings, and 44.9% occurred during normal hours. The top three chief complaints were related to pain, respiratory distress, and GI issues. Lung, breast, prostate, and colorectal cancers were identified in 26.9%, 6.3%, 6%, and 7.7% of visits, respectively, with diagnosis. A total of 63.2% of visits resulted in hospital admittance. When controlling for sex, age, time of day, day of week, insurance, and diagnosis position, patients with lung cancer were more likely to be admitted than patients with other types of cancer. CONCLUSION To the best of our knowledge, this is the first study to provide a population-based snapshot of ED visits by patients with cancer in North Carolina. Efforts that target clinical problems and specific populations may improve delivery of quality cancer care and avoid ED visits.
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Affiliation(s)
- Deborah K Mayer
- School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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134
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Howell D, Marshall D, Brazil K, Taniguchi A, Howard M, Foster G, Thabane L. A shared care model pilot for palliative home care in a rural area: impact on symptoms, distress, and place of death. J Pain Symptom Manage 2011; 42:60-75. [PMID: 21402458 DOI: 10.1016/j.jpainsymman.2010.09.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 08/05/2010] [Accepted: 09/16/2010] [Indexed: 12/25/2022]
Abstract
CONTEXT Shared care models integrating family physician services with interdisciplinary palliative care specialist teams are critical to improve access to quality palliative home care and address multiple domains of end-of-life issues and needs. OBJECTIVES To examine the impact of a shared care pilot program on the primary outcomes of symptom severity and emotional distress (patient and family separately) over time and, secondarily, the concordance between patient preferences and place of death. METHODS An inception cohort of patients (n = 95) with advanced, progressive disease, expected to die within six months, were recruited from three rural family physician group practices (21 physicians) and followed prospectively until death or pilot end. Serial measurement of symptoms, emotional distress (patient and family), and preferences for place of death was performed, with analysis of changes in distress outcomes assessed using t-tests and general linear models. RESULTS Symptoms trended toward improvement, with a significant reduction in anxiety from baseline to 14 days noted. Symptom and emotional distress were maintained below high severity (7-10), and a high rate of home death compared with population norms was observed. CONCLUSION Future controlled studies are needed to examine outcomes for shared care models with comparison groups. Shared care models build on family physician capacity and as such are promising in the development of palliative home care programs to improve access to quality palliative home care and foster health system integration.
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Affiliation(s)
- Doris Howell
- Princess Margaret Hospital, University of Toronto, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
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135
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Connell T, Griffiths R, Fernandez RS, Tran D, Agar M, Harlum J. Quality-of-life trajectory of clients and carers referred to a community palliative care service. Int J Palliat Nurs 2011; 17:80-5. [PMID: 21378692 DOI: 10.12968/ijpn.2011.17.2.80] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Palliative care clients often have a reduced quality of life (QOL). The purpose of this study was to explore the QOL trajectory of clients and carers newly referred to a community palliative care service. A total of 49 clients and 43 carers respectively completed the McGill QOL scale (MQOL) and the caregiver QOL cancer scale (CQOLC) questionnaires. Baseline data relating to demographics, health status, and QOL are presented for the 49 participants and their 43 carers, and these are compared with follow-up data from 22 clients and 13 carers (matched pairs). On average, there were no significant differences between baseline and follow-up QOL scores in any respects for either clients or carers, including measures of burden, disruptiveness, positive adaptation, and financial concerns. Whether this indicates that the care administered succeeded in cancelling out the worsening of the clients' conditions or whether it indicates a shortcoming of the care was not assessed.
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136
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Wiese CHR, Vagts DA, Kampa U, Pfeiffer G, Grom IU, Gerth MA, Graf BM, Zausig YA. [Palliative care and end-of-life patients in emergency situations. Recommendations on optimization of out-patient care]. Anaesthesist 2011; 60:161-71. [PMID: 21184035 DOI: 10.1007/s00101-010-1831-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. The goals of this study were to discuss cooperation between emergency medical and palliative care structures to optimize the quality of care in emergencies involving palliative care patients. METHODS For data collection an open discussion of the main topics by experts in palliative and emergency medical care was employed. Main outcome measures and recommendations included responses regarding current practices related to expert opinions and international literature sources. RESULTS As the essential points of consensus the following recommendations for optimization of care were named: (1) integration of palliative care in the emergency medicine curricula for pre-hospital emergency physicians and paramedics, (2) development of outpatient palliative care, (3) integration of palliative care teams into emergency medical structures, (4) cooperation between palliative and emergency medical care, (5) integration of crisis intervention into outpatient palliative emergency medical care, (6) provision of emergency plans and emergency medical boxes, (7) provision of palliative crisis cards and do not attempt resuscitation (DNAR) orders, (8) psychosocial aspects concerning palliative emergencies and (9) definition of palliative patients and their special situation by the physician responsible for prior treatment. CONCLUSIONS Prehospital emergency physicians are confronted with emergencies in palliative care patients every day. In the treatment of these emergencies there are potentially serious conflicts due to the different therapeutic concepts of palliative medical care and emergency medical services. This study demonstrates that there is a need for regulated criteria for the therapy of palliative patients and patients at the end of life in emergency situations. Overall, more clinical investigations concerning end-of-life care and unresponsive palliative care patients in emergency medical situations are necessary.
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Affiliation(s)
- C H R Wiese
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg, Germany.
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Ho TH, Barbera L, Saskin R, Lu H, Neville BA, Earle CC. Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada. J Clin Oncol 2011; 29:1587-91. [PMID: 21402603 PMCID: PMC3082976 DOI: 10.1200/jco.2010.31.9897] [Citation(s) in RCA: 327] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 01/11/2011] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To describe trends in the aggressiveness of end-of-life (EOL) cancer care in a universal health care system in Ontario, Canada, between 1993 and 2004, and to compare with findings reported in the United States. METHODS A population-based, retrospective, cohort study that used administrative data linked to registry data. Aggressiveness of EOL care was defined as the occurrence of at least one of the following indicators: last dose of chemotherapy received within 14 days of death; more than one emergency department (ED) visit within 30 days of death; more than one hospitalization within 30 days of death; or at least one intensive care unit (ICU) admission within 30 days of death. RESULTS Among 227,161 patients, 22.4% experienced at least one incident of potentially aggressive EOL cancer care. Multivariable analyses showed that with each successive year, patients were significantly more likely to encounter some aggressive intervention (odds ratio, 1.01; 95% CI, 1.01 to 1.02). Multiple emergency department (ED) visits, ICU admissions, and chemotherapy use increased significantly over time, whereas multiple hospital admissions declined (P < .05). Patients were more likely to receive aggressive EOL care if they were men, were younger, lived in rural regions, had a higher level of comorbidity, or had breast, lung, or hematologic malignancies. Chemotherapy and ICU utilization were lower in Ontario than in the United States. CONCLUSION Aggressiveness of cancer care near the EOL is increasing over time in Ontario, Canada, although overall rates were lower than in the United States. Health system characteristics and patient or physician cultural factors may play a role in the observed differences.
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Affiliation(s)
- Thi H. Ho
- From the Ontario Institute for Cancer Research; Odette Cancer Centre; Institute for Clinical Evaluative Sciences, Toronto, Ontario; and Dana-Farber Cancer Institute, Boston, MA
| | - Lisa Barbera
- From the Ontario Institute for Cancer Research; Odette Cancer Centre; Institute for Clinical Evaluative Sciences, Toronto, Ontario; and Dana-Farber Cancer Institute, Boston, MA
| | - Refik Saskin
- From the Ontario Institute for Cancer Research; Odette Cancer Centre; Institute for Clinical Evaluative Sciences, Toronto, Ontario; and Dana-Farber Cancer Institute, Boston, MA
| | - Hong Lu
- From the Ontario Institute for Cancer Research; Odette Cancer Centre; Institute for Clinical Evaluative Sciences, Toronto, Ontario; and Dana-Farber Cancer Institute, Boston, MA
| | - Bridget A. Neville
- From the Ontario Institute for Cancer Research; Odette Cancer Centre; Institute for Clinical Evaluative Sciences, Toronto, Ontario; and Dana-Farber Cancer Institute, Boston, MA
| | - Craig C. Earle
- From the Ontario Institute for Cancer Research; Odette Cancer Centre; Institute for Clinical Evaluative Sciences, Toronto, Ontario; and Dana-Farber Cancer Institute, Boston, MA
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138
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Tzuh Tang S, Hung YN, Liu TW, Lin DT, Chen YC, Wu SC, Hsia Hsu T. Pediatric End-of-Life Care for Taiwanese Children Who Died As a Result of Cancer From 2001 Through 2006. J Clin Oncol 2011; 29:890-4. [DOI: 10.1200/jco.2010.32.5639] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Patterns of aggressive end-of-life (EOL) care have not been extensively explored in a pediatric cancer population, especially outside Western countries. The purpose of this population-based study was to examine trends in aggressive pediatric EOL cancer care in Taiwan. Methods Retrospective cohort study that used administrative data among 1,208 pediatric cancer decedents from 2001 through 2006. Results Taiwanese pediatric cancer patients who died in 2001 through 2006 received aggressive EOL care. The majority of these patients in their last month of life continued to receive chemotherapy (52.5%), used intensive care (57.0%), underwent intubation (40.9%), underwent mechanical ventilation (48.2%), or spent greater than 14 days (69.5%) in hospital, and they died in an acute care hospital (78.8%). Of these pediatric cancer patients, one in four received cardiopulmonary resuscitation in the month before they died, and only 7.2% received hospice care. Among those who received hospice care, 21.8% started such care within the last 3 days of life. This pattern of aggressive EOL care did not change over the study period except for significantly decreased intubation in the last month of life. Conclusion Continued chemotherapy and heavy use of life-sustaining treatments in the last month of life coupled with lack of hospice care to support Taiwanese pediatric cancer patients dying at home may lead to multiple unplanned health care encounters, prolonged hospitalization at EOL, and eventual death in an acute care hospital for the majority of these patients. Future research should design interventions that enable Taiwanese pediatric cancer patients to receive EOL care that best meets the individual or the parental needs and preferences.
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Affiliation(s)
- Siew Tzuh Tang
- From the Chang Gung University, Kwei-Shan, Tao-Yuan; Institute of Health and Welfare Policy, National Yang-Ming University; National Taiwan University Hospital; Bureau of Health Promotion, Department of Health, Taipei; National Institute of Cancer Research, National Health Research Institute, Zhunan; Hung Kuang University, Taichung, Taiwan
| | - Yen-Ni Hung
- From the Chang Gung University, Kwei-Shan, Tao-Yuan; Institute of Health and Welfare Policy, National Yang-Ming University; National Taiwan University Hospital; Bureau of Health Promotion, Department of Health, Taipei; National Institute of Cancer Research, National Health Research Institute, Zhunan; Hung Kuang University, Taichung, Taiwan
| | - Tsang-Wu Liu
- From the Chang Gung University, Kwei-Shan, Tao-Yuan; Institute of Health and Welfare Policy, National Yang-Ming University; National Taiwan University Hospital; Bureau of Health Promotion, Department of Health, Taipei; National Institute of Cancer Research, National Health Research Institute, Zhunan; Hung Kuang University, Taichung, Taiwan
| | - Dong-Tsamn Lin
- From the Chang Gung University, Kwei-Shan, Tao-Yuan; Institute of Health and Welfare Policy, National Yang-Ming University; National Taiwan University Hospital; Bureau of Health Promotion, Department of Health, Taipei; National Institute of Cancer Research, National Health Research Institute, Zhunan; Hung Kuang University, Taichung, Taiwan
| | - Yueh-Chih Chen
- From the Chang Gung University, Kwei-Shan, Tao-Yuan; Institute of Health and Welfare Policy, National Yang-Ming University; National Taiwan University Hospital; Bureau of Health Promotion, Department of Health, Taipei; National Institute of Cancer Research, National Health Research Institute, Zhunan; Hung Kuang University, Taichung, Taiwan
| | - Shiao-Chi Wu
- From the Chang Gung University, Kwei-Shan, Tao-Yuan; Institute of Health and Welfare Policy, National Yang-Ming University; National Taiwan University Hospital; Bureau of Health Promotion, Department of Health, Taipei; National Institute of Cancer Research, National Health Research Institute, Zhunan; Hung Kuang University, Taichung, Taiwan
| | - Tsui Hsia Hsu
- From the Chang Gung University, Kwei-Shan, Tao-Yuan; Institute of Health and Welfare Policy, National Yang-Ming University; National Taiwan University Hospital; Bureau of Health Promotion, Department of Health, Taipei; National Institute of Cancer Research, National Health Research Institute, Zhunan; Hung Kuang University, Taichung, Taiwan
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139
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Goldman R. Home Palliative Care. Palliat Care 2011. [DOI: 10.1016/b978-1-4377-1619-1.00043-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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140
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Behl D, Jatoi A. What do oncologists say about chemotherapy at the very end of life? Results from a semiqualitative survey. J Palliat Med 2010; 13:831-5. [PMID: 20636153 DOI: 10.1089/jpm.2009.0414] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM This study elicited oncologists' insights into published statistics that 20% of cancer patients receive chemotherapy within 2 weeks of death and that the median survival between chemotherapy administration and death is 37 days. SUBJECTS AND METHODS A semiqualitative survey was developed to enable respondents to provide anonymous, write-in comments on the statistics above. This survey was sent electronically on two separate occasions to oncologists in the upper midwestern United States. Qualitative methods were used to analyze data. RESULTS A total of 422 oncology health-care providers were sent the survey, and 61 responded. Nine themes emerged: 1) these decisions are strongly patient-driven; 2) newer agents are driving the decision to continue with cancer treatment; 3) financial incentives on the part of the medical community explain these high rates; 4) health-care reform is necessary; 5) even a small chance of patient benefit justifies this practice; 6) this practice is detrimental to patients because it precludes the initiation of hospice services; 7) others may be prescribing in this manner, but "not us"; 8) these issues are complicated, revolve around society values, and the oncologist alone cannot claim responsibility for such high rates of chemotherapy administration; and 9) there exist barriers to end-of-life discussions. CONCLUSION Many oncologists are in fact reluctant to prescribe chemotherapy at the end of life, and the complexity of this topic underscores the potential for oncologists and palliative care providers to collaborate in an effort to provide cancer patients the best care at the very end of life.
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Affiliation(s)
- Deepti Behl
- Department of Oncology, Mayo Clinic, Rochester, Minnesota 55905, USA
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141
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Lawson BJ, Burge FI, McIntyre P, Field S, Maxwell D. Can the introduction of an integrated service model to an existing comprehensive palliative care service impact emergency department visits among enrolled patients? J Palliat Med 2010; 12:245-52. [PMID: 19231926 DOI: 10.1089/jpm.2008.0217] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Fewer emergency department (ED) visits may be a potential indicator of quality of care during the end of life. Receipt of palliative care, such as that offered by the adult Palliative Care Service (PCS) in Halifax, Nova Scotia, is associated with reduced ED visits. In June 2004, an integrated service model was introduced into the Halifax PCS with the objective of improving outcomes and enhancing care provider coordination and communication. The purpose of this study was to explore temporal trends in ED visits among PCS patients before and after integrated service model implementation. METHODS PCS and ED visit data were utilized in this secondary data analysis. Subjects included all adult patients enrolled in the Halifax PCS between January 1, 1999 and December 31, 2005, who had died during this period (N = 3221). Temporal trends in ED utilization were evaluated dichotomously as preintegration or postintegration of the new service model and across 6-month time blocks. Adjustments for patient characteristics were performed using multivariate logistic regression. RESULTS Fewer patients (29%) made at least one ED visit postintegration compared to the preintegration time period (36%, p < 0.001). Following adjustments, PCS patients enrolled postintegration were 20% less likely to have made at least one ED visit than those enrolled preintegration (adjusted OR 0.8; 95% confidence interval 0.6-1.0). CONCLUSION There is some evidence to suggest the introduction of the integrated service model has resulted in a decline in ED visits among PCS patients. Further research is needed to evaluate whether the observed reduction persists.
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Affiliation(s)
- Beverley J Lawson
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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142
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Han PKJ, Rayson D. The coordination of primary and oncology specialty care at the end of life. J Natl Cancer Inst Monogr 2010; 2010:31-7. [PMID: 20386052 DOI: 10.1093/jncimonographs/lgq003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The end of life is a time in which both the intensity of cancer patients' needs and the complexity of care increase, heightening the need for effective care coordination between oncology and primary care physicians. However, little is known about the extent to which such coordination occurs or the ways in which it is achieved. We review existing evidence on current practice patterns, patient and physician preferences regarding involvement of oncology and primary care physicians in end-of-life care, and the potential impact of care coordination on the quality of care and health outcomes. Data are lacking on the extent to which end-of-life care is coordinated between oncology and primary care physicians. Patients appear to prefer the continued involvement of both types of physicians, and preliminary evidence suggests that coordinated care improves health outcomes. However, more work needs to be done to corroborate these findings, and many unanswered questions remain.
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Affiliation(s)
- Paul K J Han
- MA, Center for Outcomes Research and Evaluation, Maine Medical Center, 39 Forest Ave., Portland, ME 04101, USA.
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143
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Post-mortal bereavement of family caregivers in Germany: a prospective interview-based investigation. Wien Klin Wochenschr 2010; 122:384-9. [DOI: 10.1007/s00508-010-1396-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Accepted: 04/29/2010] [Indexed: 11/26/2022]
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144
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Connell T, Fernandez RS, Griffiths R, Tran D, Agar M, Harlum J, Langdon R. Perceptions of the impact of health-care services provided to palliative care clients and their carers 274. Int J Palliat Nurs 2010; 16:274-84. [PMID: 20925290 DOI: 10.12968/ijpn.2010.16.6.48829] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Ritin S Fernandez
- School of Nursing and Midwifery, College of Health and Science, University of Western Sydney
| | - Rhonda Griffiths
- Centre for Applied Nursing Research, Sydney South West Area Health Service
| | - Duong Tran
- Centre for Applied Nursing Research, Sydney South West Area Health Service
| | - Meera Agar
- Staff Specialist Palliative Medicine, Braeside Hospital, New South Wales, New South Wales
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145
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Bergman J, Chi AC, Litwin MS. Quality of end-of-life care in low-income, uninsured men dying of prostate cancer. Cancer 2010; 116:2126-31. [PMID: 20198706 DOI: 10.1002/cncr.25039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The quality of end-of-life care was assessed in disadvantaged men prospectively enrolled in a public assistance program. That end-of-life care would be aggressive, more so than recommended by quality-of-care guidelines, was hypothesized. METHODS Included in the study were all 60 low-income, uninsured men in a state-funded public assistance program who had died since its inception in 2001. To measure quality of end-of-life care, information was collected regarding timing of the institution of new chemotherapeutic regimens, time from administration of last chemotherapy dose to death, the number of inpatient admissions and intensive care unit stays made in the 3 months preceding death, and the number of emergency room visits made in the 12 months before dying. Also noted were hospice use and the timing of hospice referrals. RESULTS Eighteen men (30%) enrolled in hospice before death and the average hospice stay lasted 45 days (standard deviation, 32; range, 2-143 days; median, 41 days). Two patients (11%) were enrolled for fewer than 7 days, and none were enrolled for more than 180 days. The average time from administration of the last dose of chemotherapy to death was 104 days. Chemotherapy was never initiated within 3 months of death, and in only 2 instances (6%) was the final chemotherapeutic regimen administered within 2 weeks of dying. Use of hospital resources (emergency room visits, inpatient admissions, and intensive care unit stays) was uniformly low (mean, 1.0 +/- 1.0, 0.65 +/- 0.82, and 0.03 +/- 0.18, respectively). CONCLUSIONS End-of-life care in disadvantaged men dying of prostate cancer, who enroll in a comprehensive statewide assistance program, is high-quality.
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Affiliation(s)
- Jonathan Bergman
- Department of Urology, University of California at Los Angeles, Los Angeles, California 90095-1738, USA.
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146
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Bryson J, Coe G, Swami N, Murphy-Kane P, Seccareccia D, Le LW, Rodin G, Zimmermann C. Administrative Outcomes Five Years after Opening an Acute Palliative Care Unit at a Comprehensive Cancer Center. J Palliat Med 2010; 13:559-65. [DOI: 10.1089/jpm.2009.0373] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John Bryson
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Canada
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
| | - Gary Coe
- Department of Medical Oncology, Princess Margaret Hospital, University Health Network, Canada
| | - Nadia Swami
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
- Ontario Cancer Institute, Princess Margaret Hospital, University Health Network, Canada
| | - Patricia Murphy-Kane
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
| | - Dori Seccareccia
- Department of Family and Community Medicine, University of Toronto, Canada
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
| | - Lisa W. Le
- Department of Biostatistics, Princess Margaret Hospital, University Health Network, Canada
| | - Gary Rodin
- Department of Psychiatry, University of Toronto, Canada
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
- Ontario Cancer Institute, Princess Margaret Hospital, University Health Network, Canada
| | - Camilla Zimmermann
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Canada
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
- Ontario Cancer Institute, Princess Margaret Hospital, University Health Network, Canada
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147
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Wu SC, Chen JS, Wang HM, Hung YN, Liu TW, Tang ST. Determinants of ICU care in the last month of life for Taiwanese cancer decedents, 2001 to 2006. Chest 2010; 138:1071-7. [PMID: 20363837 DOI: 10.1378/chest.09-2662] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Use of the hospital ICU is rising rapidly for end-of-life care. The purpose of this population-based study was to determine the prevalence of ICU care in the last month of life of patients with cancer and the associations between ICU care and patient demographics, disease characteristics, physician specialty, hospital characteristics, and availability of health-care resources at the hospital and regional levels in Taiwan. METHODS This retrospective cohort study used administrative data for 204,850 cancer decedents from 2001 to 2006. RESULTS Rates of hospital ICU care in the last month of life did not change significantly from 2001 to 2006 (11.27%-12.71%). ICU use in the last month of life was more likely for single male patients aged < 65 years who had hematologic malignancies or esophageal cancer and more comorbidities or a nononcologist as primary-care physician. Patients with cancer were one-third less likely to use ICU care in their last month of life if they received care in a private hospital than if they were cared for in a public hospital. Patient propensity to receive ICU care in the last month of life was positively associated with increasing quartile of total hospital beds in their primary hospital's region. CONCLUSIONS Slightly more than one-tenth of Taiwanese patients with cancer received ICU care in their last month of life. ICU use was strongly influenced by receiving care in hospitals and regions with abundant health-care resources. Resources should be devoted to ensure that ICU care at the end of life best meets patients' individual needs and interests.
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Affiliation(s)
- Shiao-Chi Wu
- Institute of Health and Welfare Policy, National Yang-Ming University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
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148
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Wiese CHR, Bartels U, Ruppert D, Marung H, Graf BM, Hanekop GG. [Emergency outpatient palliative care in acute situations by paramedics]. Wien Klin Wochenschr 2010; 120:539-46. [PMID: 18988007 DOI: 10.1007/s00508-008-1018-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 07/09/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND In recent years outpatient palliative care, even for patients in an advanced state of their disease, has gained importance. Therefore, also paramedics are more often confronted with palliative emergencies, advance directives, and ethical end-of-life issues. Presently in emergency medicine there is undoubtedly a lack of education on palliative medicine and ethical questions for paramedics. METHODS In a period of six months we questioned 250 paramedics from two German regions (Göttingen and Braunschweig) about their experiences in palliative medicine, palliative emergencies and about their knowledge of advance directives. For these key questions we drew up a specific questionnaire. RESULTS The response rate in the set period of time amounted to 64.8% (n = 162). Most of the interviewed paramedics (91.4%, n = 148) had been confronted with palliative emergency situations on duty. 47.6% felt uncertain about the correct psychosocial care of the patients. 84% of the paramedics were insecure concerning their knowledge about advance directives. 72.8% had already taken care of patients with advance directives. These advance directives had influenced their therapy decision in 42.8%. CONCLUSION The emergency treatment of palliative patients can present a particular challenge to paramedics. Most of the interviewed paramedics felt insecure both about the social care and the assessment of legal issues in dealing with advance directives and decisions at the end of life. Therefore emergency medical training apparently needs to be improved in these fields. Further information and training are necessary to guarantee adequate patient-oriented care of palliative patients und their relatives also in emergency situations.
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Affiliation(s)
- Christoph H R Wiese
- Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin der Georg-August-Universität Göttingen, Germany.
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Using more end-of-life homecare services is associated with using fewer acute care services: a population-based cohort study. Med Care 2010; 48:118-24. [PMID: 20057327 DOI: 10.1097/mlr.0b013e3181c162ef] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Healthcare systems are investing in end-of-life homecare to reduce acute care use. However, little evidence exists on the timing and amount of homecare services necessary to reduce acute care utilization. OBJECTIVES To investigate whether admission time to homecare and the amount of services, as measured by average nursing and personal support and homemaking (PSH) hours/week (h/wk), are associated with using acute care services at end-of-life. RESEARCH DESIGN Retrospective observational cohort study. SUBJECTS Decedents admitted to end-of-life homecare in Ontario, Canada. MEASURES The odds ratios (OR) of having a hospitalization or emergency room visit in the 2 weeks before death and dying in a hospital. RESULTS The cohort (n = 9018) used an average of 3.11 (SD = 4.87) nursing h/wk, 3.18 (SD = 6.89) PSH h/wk, and 18% were admitted to homecare for <1 month. As admission time to death and homecare services increased, the adjusted OR of an outcome decreased in a dose response manner. Patients admitted earlier than 6 months before death had a 35% (95% CI: 25%-44%) lower OR of hospitalization than those admitted 3 to 4 weeks before death; patients using more than 7 nursing h/wk and more than 7 PSH h/wk had a 50% (95% CI: 37%-60%) and 35% (95% CI: 21%-47%) lower OR of a hospitalization, respectively, than patients using 1 h/wk, controlling for other covariates. Other outcomes had similar results. CONCLUSION These results suggest that early homecare admission and increased homecare services will help alleviate the demand for hospital resources at end-of-life.
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Notärztliche Betreuung kinderpalliativmedizinischer Notfallsituationen – ein Problem für den Rettungsdienst? – Eine retrospektive, multizentrische Beobachtungsstudie. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2010; 104:143-9. [DOI: 10.1016/j.zefq.2009.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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