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Yarnell CJ, Jewell LM, Astell A, Pinto R, Devine LA, Detsky ME, Downar J, Ilan R, Rawal S, Wong N, You JJ, Fowler RA. Observational study of agreement between attending and trainee physicians on the surprise question: "Would you be surprised if this patient died in the next 12 months?". PLoS One 2021; 16:e0247571. [PMID: 33630939 PMCID: PMC7906409 DOI: 10.1371/journal.pone.0247571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Optimal end-of-life care requires identifying patients that are near the end of life. The extent to which attending physicians and trainee physicians agree on the prognoses of their patients is unknown. We investigated agreement between attending and trainee physician on the surprise question: "Would you be surprised if this patient died in the next 12 months?", a question intended to assess mortality risk and unmet palliative care needs. METHODS This was a multicentre prospective cohort study of general internal medicine patients at 7 tertiary academic hospitals in Ontario, Canada. General internal medicine attending and senior trainee physician dyads were asked the surprise question for each of the patients for whom they were responsible. Surprise question response agreement was quantified by Cohen's kappa using Bayesian multilevel modeling to account for clustering by physician dyad. Mortality was recorded at 12 months. RESULTS Surprise question responses encompassed 546 patients from 30 attending-trainee physician dyads on academic general internal medicine teams at 7 tertiary academic hospitals in Ontario, Canada. Patients had median age 75 years (IQR 60-85), 260 (48%) were female, and 138 (25%) were dependent for some or all activities of daily living. Trainee and attending physician responses agreed in 406 (75%) patients with adjusted Cohen's kappa of 0.54 (95% credible interval 0.41 to 0.66). Vital status was confirmed for 417 (76%) patients of whom 160 (38% of 417) had died. Using a response of "No" to predict 12-month mortality had positive likelihood ratios of 1.84 (95% CrI 1.55 to 2.22, trainee physicians) and 1.51 (95% CrI 1.30 to 1.72, attending physicians), and negative likelihood ratios of 0.31 (95% CrI 0.17 to 0.48, trainee physicians) and 0.25 (95% CrI 0.10 to 0.46, attending physicians). CONCLUSION Trainee and attending physician responses to the surprise question agreed in 54% of cases after correcting for chance agreement. Physicians had similar discriminative accuracy; both groups had better accuracy predicting which patients would survive as opposed to which patients would die. Different opinions of a patient's prognosis may contribute to confusion for patients and missed opportunities for engagement with palliative care services.
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Affiliation(s)
- Christopher J. Yarnell
- Institute of Health Management, Policy, and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Laura M. Jewell
- Memorial University of Newfoundland, Discipline of Family Medicine, Happy Valley-Goose Bay, Canada
| | - Alex Astell
- University of Manitoba Faculty of Medicine, Section of Critical Care Medicine, Manitoba, Canada
| | - Ruxandra Pinto
- Sunnybrook Health Sciences Centre Department of Critical Care, Toronto, Canada
| | - Luke A. Devine
- Department of Medicine, Sinai Health System, Toronto, Canada
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
| | - Michael E. Detsky
- Department of Medicine, Sinai Health System, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - James Downar
- The Ottawa Hospital, Ottawa, Canada
- University of Ottawa Faculty of Medicine, Division of Palliative Care, Ottawa, Canada
| | - Roy Ilan
- Department of Critical Care Medicine, Rambam Health Care Campus, Technion, Israel Institute of Technology, Haifa, Israel
| | - Shail Rawal
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
- University Health Network, General Internal Medicine, Toronto, Canada
| | - Natalie Wong
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
- Departments of General Internal Medicine and Critical Care Medicine, St Michael’s Hospital, Toronto, Canada
| | - John J. You
- Division of General Internal and Hospitalist Medicine, Department of Medicine, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Rob A. Fowler
- Institute of Health Management, Policy, and Evaluation, University of Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre Department of Critical Care, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
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102
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Owusuaa C, van Beelen I, van der Heide A, van der Rijt CCD. Physicians' views on the usefulness and feasibility of identifying and disclosing patients' last phase of life: a focus group study. BMJ Support Palliat Care 2021:bmjspcare-2020-002764. [PMID: 33619221 DOI: 10.1136/bmjspcare-2020-002764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Accurate assessment that a patient is in the last phase of life is a prerequisite for timely initiation of palliative care in patients with a life-limiting disease, such as advanced cancer or advanced organ failure. Several palliative care quality standards recommend the surprise question (SQ) to identify those patients. Little is known about physicians' views on identifying and disclosing the last phase of life of patients with different illness trajectories. METHODS Data from two focus groups were analysed using thematic analysis with a phenomenological approach. RESULTS Fifteen medical specialists and general practitioners participated. Participants thought prediction of patients' last phase of life, i.e. expected death within 1 year, is important. They seemed to find that prediction is more difficult in patients with advanced organ failure compared with cancer. The SQ was considered a useful prognostic tool; its use is facilitated by its simplicity but hampered by its subjective character. The medical specialist was considered mainly responsible for prognosticating and gradually disclosing the last phase. Participants' reluctance to such disclosure was related to uncertainty around prognostication, concerns about depriving patients of hope, affecting the physician-patient relationship, or a lack of time or availability of palliative care services. CONCLUSIONS Physicians consider the assessment of patients' last phase of life important and support use of the SQ in patients with different illness trajectories. However, barriers in disclosing expected death are prognostic uncertainty, possible deprivation of hope, physician-patient relationship, and lack of time or palliative care services. Future studies should examine patients' preferences for those discussions.
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Affiliation(s)
- Catherine Owusuaa
- Medical Oncology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Irene van Beelen
- Medical Oncology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
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103
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Sripaew S, Fumaneeshoat O, Ingviya T. Systematic adaptation of the Thai version of the supportive and palliative care indicators tool for low-income setting (SPICT-LIS). BMC Palliat Care 2021; 20:35. [PMID: 33607991 PMCID: PMC7896360 DOI: 10.1186/s12904-021-00729-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 02/12/2021] [Indexed: 11/25/2022] Open
Abstract
Background Identification of patients who might benefit from palliative care among countries with different socioeconomic and medical contexts is challenging. The Supportive and Palliative Care Indicators Tool for a Low-income Setting (SPICT-LIS) was designed to help physicians identify patients in low-income setting who might benefit from palliative care. We aimed to systematically adapt and refine the SPICT-LIS for Thai general palliative care providers. Methods We followed the WHO guidelines for translation, cross-cultural adaptation and validation of an instrument for the SPICT-LIS. Three expert panel members did the initial adaptation using forward and backward translations with pretested data. Two iterations of pretesting were conducted to test for applicability and reliability. The case vignettes which were used in the pretesting were modified hospital medical records. The pretesting was done with 30 respondents from various specialties in a community health center and 34 general palliative care providers from a regional referral hospital in the first and second iterations, respectively. To examine instrument reliability, interrater reliability and internal consistency were evaluated. Cognitive interviewing was conducted using semi-structured interviews with general practitioners (GPs) using the “think aloud strategy” and “probing questions”. Results The adapted Thai SPICT-LIS had a total of 34 indicators which included 6 general and 28 clinical indicators. The assessment of the adapted Thai SPICT-LIS found that it provided consistent responses with good agreement among the GPs, with a Fleiss kappa coefficient of 0.93 (0.76–1.00). The administration time was 2.3–4.3 min per case. Most respondents were female. The 8 interviewed GPs said they felt that the SPICT-LIS was appropriate for use in a general setting in Thailand. Conclusion The study found that the Thai SPICT-LIS could be an applicable, acceptable, and reliable tool for general palliative care providers in Thailand to identify patients who might benefit from palliative care.
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Affiliation(s)
- Supakorn Sripaew
- Department of Family and Preventive Medicine, Prince of Songkla University, Faculty of Medicine, Hat Yai, Songkhla, 90110, Thailand.
| | - Orapan Fumaneeshoat
- Department of Family and Preventive Medicine, Prince of Songkla University, Faculty of Medicine, Hat Yai, Songkhla, 90110, Thailand
| | - Thammasin Ingviya
- Department of Family and Preventive Medicine, Prince of Songkla University, Faculty of Medicine, Hat Yai, Songkhla, 90110, Thailand.,Research Center for Cancer Control, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.,Medical Data Center for Research and Innovation, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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104
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Kasdorf A, Dust G, Vennedey V, Rietz C, Polidori MC, Voltz R, Strupp J. What are the risk factors for avoidable transitions in the last year of life? A qualitative exploration of professionals' perspectives for improving care in Germany. BMC Health Serv Res 2021; 21:147. [PMID: 33588851 PMCID: PMC7885553 DOI: 10.1186/s12913-021-06138-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/31/2021] [Indexed: 11/18/2022] Open
Abstract
Background Little is known about the nature of patients’ transitions between healthcare settings in the last year of life (LYOL) in Germany. Patients often experience transitions between different healthcare settings, such as hospitals and long-term facilities including nursing homes and hospices. The perspective of healthcare professionals can therefore provide information on transitions in the LYOL that are avoidable from a medical perspective. This study aims to explore factors influencing avoidable transitions across healthcare settings in the LYOL and to disclose how these could be prevented. Methods Two focus groups (n = 11) and five individual interviews were conducted with healthcare professionals working in hospitals, hospices and nursing services from Cologne, Germany. They were asked to share their observations about avoidable transitions in the LYOL. The data collection continued until the point of information power was reached and were audio recorded and analysed using qualitative content analysis. Results Four factors for potentially avoidable transitions between care settings in the LYOL were identified: healthcare system, organization, healthcare professional, patient and relatives. According to the participants, the most relevant aspects that can aid in reducing unnecessary transitions include timely identification and communication of the LYOL; consideration of palliative care options; availability and accessibility of care services; and having a healthcare professional taking main responsibility for care planning. Conclusions Preventing avoidable transitions by considering the multicomponent factors related to them not only immediately before death but also in the LYOL could help to provide more value-based care for patients and improving their quality of life. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06138-4.
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Affiliation(s)
- Alina Kasdorf
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.
| | - Gloria Dust
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Vera Vennedey
- Institute for Health Economics and Clinical Epidemiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Christian Rietz
- Department of Educational Science and Mixed-Methods-Research, University of Education Heidelberg, Faculty of Educational and Social Sciences, Heidelberg, Germany
| | - Maria C Polidori
- Department II of Internal Medicine and Cologne Center for Molecular Medicine, Ageing Clinical Research, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Cluster of Excellence CECAD, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Clinical Trials Center (ZKS), University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Center for Health Services Research, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Julia Strupp
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
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105
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Wang RF, Lai CC, Fu PY, Huang YC, Huang SJ, Chu D, Lin SP, Chaou CH, Hsu CY, Chen HH. A-qCPR risk score screening model for predicting 1-year mortality associated with hospice and palliative care in the emergency department. Palliat Med 2021; 35:408-416. [PMID: 33198575 DOI: 10.1177/0269216320972041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Evaluating the need for palliative care and predicting its mortality play important roles in the emergency department. AIM We developed a screening model for predicting 1-year mortality. DESIGN A retrospective cohort study was conducted to identify risk factors associated with 1-year mortality. Our risk scores based on these significant risk factors were then developed. Its predictive validity performance was evaluated using area under receiving operating characteristic analysis and leave-one-out cross-validation. SETTING AND PARTICIPANTS Patients aged 15 years or older were enrolled from June 2015 to May 2016 in the emergency department. RESULTS We identified five independent risk factors, each of which was assigned a number of points proportional to its estimated regression coefficient: age (0.05 points per year), qSOFA ⩾ 2 (1), Cancer (4), Eastern Cooperative Oncology Group Performance Status score ⩾ 2 (2), and Do-Not-Resuscitate status (3). The sensitivity, specificity, positive predictive value, and negative predictive value of our screening tool given the cutoff larger than 3 points were 0.99 (0.98-0.99), 0.31 (0.29-0.32), 0.26 (0.24-0.27), and 0.99 (0.98-1.00), respectively. Those with screening scores larger than 9 points corresponding to 64.0% (60.0-67.9%) of 1-year mortality were prioritized for consultation and communication. The area under the receiving operating characteristic curves for the point system was 0.84 (0.83-0.85) for the cross-validation model. CONCLUSIONS A-qCPR risk scores provide a good screening tool for assessing patient prognosis. Routine screening for end-of-life using this tool plays an important role in early and efficient physician-patient communications regarding hospice and palliative needs in the emergency department.
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Affiliation(s)
- Ruei-Fang Wang
- Department of Emergency Medicine, Taipei City Hospital, Taipei
| | - Chao-Chih Lai
- Department of Emergency Medicine, Taipei City Hospital, Taipei
- Master of Public Health Program, College of Public Health, National Taiwan University, Taipei
| | - Ping-Yeh Fu
- Department of Emergency Medicine, Taipei City Hospital, Taipei
| | | | | | - Dachen Chu
- Superintendent, Taipei City Hospital
- National Yang-Ming University, Taipei
| | - Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan City
| | - Chen-Yang Hsu
- Master of Public Health Program, College of Public Health, National Taiwan University, Taipei
- Da-Chung Hospital, Miaoli
| | - Hsiu-Hsi Chen
- Division Biostatistics, Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
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106
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Sinha S, Subramoney K, Fraser M, Howard J, Sadowski J, Azar J, Kara A. Using a Modified Surprise Question as a Tool to Improve Primary Palliative Care in a Neurocritical Care Unit. Jt Comm J Qual Patient Saf 2021; 47:228-233. [PMID: 33451896 DOI: 10.1016/j.jcjq.2020.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Specialty palliative care is a limited resource. The surprise question ("Would you be surprised if this patient died within the next 12 months?") is a screening tool for clinicians to identify people nearing the end of life. The researchers used a modified surprise question (MSQ) to improve primary palliative care in a neurocritical care unit. METHODS A palliative care physician attended interdisciplinary rounds up to three days a week and asked the primary neurocritical care team, for each patient admitted in the previous 24 hours, the MSQ: "Would you be surprised if this patient died during this hospital stay?" If the response was "No," the unit social worker identified the patient's surrogate decision maker (SDM), and the primary team was encouraged to conduct a goals of care (GOC) conversation. The frequency of SDM documentation, occurrence and timing of GOC conversations, and palliative care and hospice consultations were measured for the baseline six months before the intervention, and six months after. RESULTS Among 350 patients admitted to the neurocritical care unit during the study, the age, gender, prehospitalization presence of advance directives, and mortality were comparable between the baseline (n = 173) and intervention (n = 177) periods. Compared to the baseline period, there was a higher frequency during the intervention period of documentation of SDM (31.8% vs. 54.2%, p = 0.00002), all GOC conversations (35.3% vs. 53.1%, p = 0.008), GOC conversations conducted by the primary team (27.2% vs. 47.5%, p = 0.00009), palliative care consultations (11.6% vs. 23.2%, p = 0.004), and hospice consultations (2.3% vs. 9.6%, p = 0.004). CONCLUSION The MSQ can be used as a tool to identify the risk of mortality, facilitate palliative care delivered by the primary team, and improve end-of-life care.
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107
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SURvival PRediction In SEverely Ill Patients Study-The Prediction of Survival in Critically Ill Patients by ICU Physicians. Crit Care Explor 2021; 3:e0317. [PMID: 33458684 DOI: 10.1097/cce.0000000000000317] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The surprise question, "Would I be surprised if this patient died in the next 12 months?" is a tool to identify patients at high risk of death in the next year. Especially in the situation of an ICU admission, it is important to recognize patients who could and could not have the benefits of an intensive treatment in the ICU department. Design and Setting A single-center, prospective, observational cohort study was conducted between April 2013 and April 2018, in ICU Gelre hospitals, location Apeldoorn. Patients A total of 3,140 patients were included (57% male) with a mean age of 63.5 years. Seven-hundred thirteen patients (23%) died within 1 year. Interventions The physician answered three different surprise question's with either "yes" or "no": "I expect that the patient is going to survive the ICU admission" (surprise question 1), "I expect that the patient is going to survive the hospital stay" (surprise question 2), and "I expect that the patient is going to survive one year after ICU admission" (surprise question 3). We tested positive and negative predicted values of the surprise questions, the mean accuracy of the surprise questions, and kappa statistics. Measurements and Main Results The positive and negative predictive values of the surprise questions for ICU admission, hospital admission, and 1-year survival were, respectively, 64%/94%, 59%/92%, and 60%/86%. Accordingly, the mean accuracy and kappa statistics were 93% (95% CI, 92-94%), κ equals to 0.43, 89% (95% CI, 88-90%), κ equals to 0.40, and 81% (95% CI, 80-82%), κ equals to 0.43. Conclusions The frequently overlooked simple and cheap surprise question is probably an useful tool to evaluate the prognosis of acutely admitted critically ill patients.
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108
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Mohan D, Sacks OA, O'Malley J, Rudolph M, Bynum J, Murphy M, Barnato AE. A New Standard for Advance Care Planning (ACP) Conversations in the Hospital: Results from a Delphi Panel. J Gen Intern Med 2021; 36:69-76. [PMID: 32816240 PMCID: PMC7859119 DOI: 10.1007/s11606-020-06150-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 07/22/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Fewer than half of the US population has an advance healthcare directive. Hospitalizations offer a key opportunity for clinicians to engage patients in advance care planning (ACP) conversations. Guidelines suggest screening for the presence of "serious illness" but do not further specify how to prioritize the 12.4 million patients hospitalized each year. OBJECTIVE To establish a normative standard for prioritizing hospitalized patients for ACP conversations. DESIGN AND SETTING A modified Delphi study, with three iterative rounds of online surveys. PARTICIPANTS Multi-disciplinary group of US-based clinicians with research and practical expertise in ACP. MAIN MEASURES Indirect and direct elicitation of short-term and 1-year risk of mortality that prompt experts to prioritize ACP conversations for hospitalized adults. MAIN RESULTS Fifty-seven of 108 (52%) candidate panelists completed round 1, and 47 completed rounds 2 and 3. Panelists were primarily physicians (84%), with significant experience (mean years 23 [SD 9.8]), who either taught (55%) and/or performed research about ACP (55%). In round 1, > 70% of panelists agreed that all hospitalized adults ≥ 65 years should have an ACP conversation before discharge, but disagreed about the timing and content of the conversation. By round 3, > 70% of participants agreed that patients with either high (> 10%) short-term or high (≥ 34%) 1-year risk of mortality should have a goals of care conversation (i.e., focused on preferences for near-term treatment), while patients with low (≤ 10%) short-term and low (< 19%) 1-year risk of mortality warranted an ACP conversation (i.e., focused on preferences for future care) before discharge. LIMITATIONS Use of case vignettes to elicit clinician judgment; response rate. CONCLUSIONS Panelists agreed that clinicians should have an ACP conversation with all hospitalized adults over 65 years in an ACP conversation, adjusting the content and timing of the conversation conditional on the patient's risk of short-term and 1-year mortality.
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Affiliation(s)
- Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Olivia A Sacks
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - Julie Bynum
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Megan Murphy
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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109
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Ament SM, Couwenberg IM, Boyne JJ, Kleijnen J, Stoffers HE, van den Beuken MH, Engels Y, Bellersen L, Janssen DJ. Tools to help healthcare professionals recognize palliative care needs in patients with advanced heart failure: A systematic review. Palliat Med 2021; 35:45-58. [PMID: 33054670 PMCID: PMC7797617 DOI: 10.1177/0269216320963941] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The delivery of palliative care interventions is not widely integrated in chronic heart failure care as the recognition of palliative care needs is perceived as difficult. Tools may facilitate healthcare professionals to identify patients with palliative care needs in advanced chronic heart failure. AIM To identify tools to help healthcare professionals recognize palliative care needs in patients with advanced chronic heart failure. DESIGN This systematic review was registered in the PROSPERO database (CRD42019131896). Evidence of tools' development, evaluation, feasibility, and implementation was sought and described. DATA SOURCES Electronic searches to identify references of tools published until June 2019 were conducted in MEDLINE, CINAHL, and EMBASE. Hand-searching of references and citations was undertaken. Based on the identified tools, a second electronic search until September 2019 was performed to check whether all evidence about these tools in the context of chronic heart failure was included. RESULTS Nineteen studies described a total of seven tools. The tools varied in purpose, intended user and properties. The tools have been validated to a limited extent in the context of chronic heart failure and palliative care. Different health care professionals applied the tools in various settings at different moments of the care process. Guidance and instruction about how to apply the tool revealed to be relevant but may be not enough for uptake. Spiritual care needs were perceived as difficult to assess. CONCLUSION Seven tools were identified which showed different and limited levels of validity in the context of palliative care and chronic heart failure.
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Affiliation(s)
- Stephanie Mc Ament
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Inge Me Couwenberg
- Department of Cardiology, Catharina Hospital, Eindhoven, North Brabant, The Netherlands
| | - Josiane Jj Boyne
- Department of Patient and Care, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Jos Kleijnen
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.,Kleijnen Systematic Reviews Ltd, York, UK
| | - Henri Ejh Stoffers
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Marieke Hj van den Beuken
- Centre of Expertise for Palliative Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Louise Bellersen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Daisy Ja Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.,Department of Research and Education, Ciro, Horn, The Netherlands
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Ikari T, Hiratsuka Y, Yamaguchi T, Maeda I, Mori M, Uneno Y, Taniyama T, Matsuda Y, Oya K, Tagami K, Inoue A. "3-Day Surprise Question" to predict prognosis of advanced cancer patients with impending death: Multicenter prospective observational study. Cancer Med 2020; 10:1018-1026. [PMID: 33347734 PMCID: PMC7897938 DOI: 10.1002/cam4.3689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 12/08/2020] [Indexed: 11/18/2022] Open
Abstract
Background The study aimed to clarify the efficacy of the “3‐Day Surprise Question (3DSQ)” in predicting the prognosis for advanced cancer patients with impending death. Patients and Methods This study was a part of multicenter prospective observational study which investigated the dying process in advanced cancer patients in Japan. For patients with a Palliative Performance Scale ≤20, the 3DSQ “Would I be surprised if this patient died in the next 3 days?” was answered by their physicians. In addition to the sensitivity and specificity of the 3DSQ, the characteristics of patients who survived longer than expected were examined via multivariate analysis. Results Among the 1896 patients enrolled, 1411 were evaluated. Among 1179 (83.6%) patients who were classified into the “Not surprised” group, 636 patients died within 3 days. Among 232 (16.4%) patients of “Yes surprised” group, 194 patients lived longer than 3 days. The sensitivity, specificity, positive predictive value, and negative predictive value of the 3DSQ were 94.3% (95% confidence interval [CI]: 92.7% to 95.8%), 26.3% (95% CI: 24.8% to 27.6%), 53.9% (95% CI: 53.0% to 54.7%), and 83.6% (95% CI: 78.7% to 87.7%), respectively. Multivariate analysis showed palpable radial artery, absent respiration with mandibular movement, SpO2 ≥ 90%, opioid administration, and no continuous deep sedation as characteristics of patients who lived longer than expected. Conclusions The 3‐Day Surprise Question can be a useful screening tool to identify advanced cancer patients with impending death.
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Affiliation(s)
- Tomoo Ikari
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Yusuke Hiratsuka
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University School of Medicine, Sendai, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-Chuo Hospital, Toyonaka, Japan
| | - Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yu Uneno
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomohiko Taniyama
- Department of Oncology and Palliative Medicine, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Yosuke Matsuda
- Palliative Care Department, St. Luke's International Hospital, Tokyo, Japan
| | - Kiyofumi Oya
- Aso Iizuka Hospital, Transitional and Palliative Care, Iizuka ciyu, Japan
| | - Keita Tagami
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Akira Inoue
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
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Where do GPs find patients with possible palliative care needs? A cross-sectional descriptive study. BJGP Open 2020; 5:BJGPO.2020.0100. [PMID: 33293409 PMCID: PMC8170618 DOI: 10.3399/bjgpo.2020.0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/28/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND For GPs to implement early palliative care, the first step is to identify patients with palliative care needs. The surprise question (SQ) is a screening tool that aims to aid this identification; for example, a response of 'no' to the SQ - 'Would you be surprised if this patient would die within a year?' - would suggest palliative care may be needed. AIM To describe setting-specific screening results of patients eligible for early palliative care in family practices, which is defined as patients aged ≥45 years with GPs' responses of 'no' to the SQ. DESIGN & SETTING A secondary analysis was undertaken using a cross-sectional descriptive study in family practices in five areas in Belgium. METHOD GPs were recruited by targeted sampling. As a first part of an implementation research project, participating GPs provided demographic information about themselves and also provided a response to the SQ for all patients who came to the practice in 10 consecutive office days. A summary table describing the sex, age, location of contact (GP surgeries, patients' homes, or nursing homes) of the patients was provided by each GP. RESULTS Fifty-six GPs provided complete data for the practice summary tables. In total, 9150 patients were described (all ages, all settings), of which 506 patients (6%) had a GP response of 'no' to the SQ. The distribution of SQ-no-as-answer patients per setting was: 152/7659 (2%) patients seen in family practice surgeries; 139/998 (14%) patients seen in their homes; and 215/493 (44%) patients seen in nursing homes. CONCLUSION There was a large number of patients with SQ-no-as-answer, with possible palliative care needs. To enhance implementation of early palliative care, future research should compare results of SQ and other screening tools with palliative care symptoms assessments.
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Lupu DE, Aldous A, Harbert G, Kurella Tamura M, Holdsworth LM, Nicklas A, Vinson B, Moss AH. Pathways Project: Development of a Multimodal Innovation To Improve Kidney Supportive Care in Dialysis Centers. KIDNEY360 2020; 2:114-128. [PMID: 35368811 PMCID: PMC8785737 DOI: 10.34067/kid.0005892020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/23/2020] [Indexed: 02/04/2023]
Abstract
Current care models for older patients with kidney failure in the United States do not incorporate supportive care approaches. The absence of supportive care contributes to poor symptom management and unwanted forms of care at the end of life. Using an Institute for Healthcare Improvement Collaborative Model for Achieving Breakthrough Improvement, we conducted a focused literature review, interviewed implementation experts, and convened a technical expert panel to distill existing evidence into an evidence-based supportive care change package. The change package consists of 14 best-practice recommendations for the care of patients seriously ill with kidney failure, emphasizing three key practices: systematic identification of patients who are seriously ill, goals-of-care conversations with identified patients, and care options to respond to patient wishes. Implementation will be supported through a collaborative consisting of three intensive learning sessions, monthly learning and collaboration calls, site data feedback, and quality-improvement technical assistance. To evaluate the change package's implementation and effectiveness, we designed a mixed-methods hybrid study involving the following: (1) effectiveness evaluation (including patient outcomes and staff perception of the effectiveness of the implementation of the change package); (2) quality-improvement monitoring via monthly tracking of a suite of quality-improvement indicators tied to the change package; and (3) implementation evaluation conducted by the external evaluator using mixed methods to assess implementation of the collaborative processes. Ten dialysis centers across the country, treating approximately 1550 patients, will participate. This article describes the process informing the intervention design, components of the intervention, evaluation design and measurements, and preliminary feasibility assessments. Clinical Trial registry name and registration number Pathways Project: Kidney Supportive Care, NCT04125537.
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Affiliation(s)
- Dale E. Lupu
- School of Nursing, George Washington University, Washington, DC
| | - Annette Aldous
- Milken Institute School of Public Health, George Washington University, Washington, DC
| | | | - Manjula Kurella Tamura
- Palo Alto Veterans Affairs Health Care System, Palo Alto, California,Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Laura M. Holdsworth
- Primary Care and Population Health, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Amanda Nicklas
- School of Nursing, George Washington University, Washington, DC
| | | | - Alvin H. Moss
- Sections of Nephrology and Palliative Medicine, School of Medicine, West Virginia University, Morgantown, West Virginia
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113
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Mojica-Márquez AE, Rodríguez-López JL, Patel AK, Ling DC, Rajagopalan MS, Beriwal S. Physician-Predicted Prognosis and Palliative Radiotherapy Treatment Utilization at the End of Life: An Audit of a Large Cancer Center Network. J Pain Symptom Manage 2020; 60:898-905.e7. [PMID: 32599149 DOI: 10.1016/j.jpainsymman.2020.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/17/2022]
Abstract
CONTEXT At our institution, clinical pathways capture physicians' prognostication of patients being evaluated for palliative radiotherapy. We hypothesize a low utilization rate of long-course radiotherapy (LCRT) and stereotactic ablative radiotherapy (SAbR) among patients seen at the end of life, especially those with physician-predicted poor prognosis. OBJECTIVE To analyze utilization rates and predictors of LCRT and SAbR at the end of life. METHODS A retrospective review was conducted on patients who were evaluated for palliative radiotherapy between January 2017 and August 2019 and died within 90 days of consultation. Binary logistic regression was used to identify predictors for utilization of LCRT (≥10 fractions) and SAbR. RESULTS A total of 1608 patients were identified, of which 1038 patients (64.6%) were predicted to die within a year. Six hundred ninety-three patients (66.8%) out of 1038 were prescribed LCRT or SAbR. On a multivariate analysis, patients were less likely to be prescribed LCRT if treated at an academic site (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.23-0.39; P < 0.01) and treated for bone metastases (OR, 0.08; 95% CI, 0.05-0.11; P < 0.01) or other nonbrain/nonbone metastases (OR, 0.19; 95% CI, 0.13-0.30; P < 0.01). SAbR was less likely to be prescribed among patients predicted to die within a year (OR, 0.09; 95% CI, 0.06-0.16; P < 0.01), treated for bone metastases (OR, 0.13; 95% CI, 0.07-0.22; P < 0.01), with poor performance status (OR, 0.51; 95% CI, 0.31-0.85; P = 0.01), and with a breast primary (OR, 0.35; 95% CI, 0.15-0.82; P = 0.02). CONCLUSION Although most patients were predicted to have a limited prognosis, LCRT and SAbR were commonly prescribed at the end of life.
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Affiliation(s)
| | - Joshua L Rodríguez-López
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ankur K Patel
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Diane C Ling
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Lapid MI, Koopmans R, Sampson EL, Van den Block L, Peisah C. Providing quality end-of-life care to older people in the era of COVID-19: perspectives from five countries. Int Psychogeriatr 2020; 32:1345-1352. [PMID: 32389141 PMCID: PMC7251283 DOI: 10.1017/s1041610220000836] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 01/15/2023]
Affiliation(s)
- Maria I. Lapid
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Raymond Koopmans
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Joachim en Anna, Center for Specialized Geriatric Care, Nijmegen, The Netherlands
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
- Barnet, Enfield and Haringey Mental Health Liaison Service, North Middlesex University Hospital NHS Trust, London, UK
| | - Lieve Van den Block
- Aging and Palliative Care, VUB-UGhent End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Brussels, Belgium
| | - Carmelle Peisah
- University New South Wales, Kensington, Australia
- Sydney University, Sydney, Australia
- Capacity Australia, Sydney, Australia
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115
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Senderovich H, McFadyen K. Palliative Care: Too Good to Be True? Rambam Maimonides Med J 2020; 11:RMMJ.10394. [PMID: 32213278 PMCID: PMC7571433 DOI: 10.5041/rmmj.10394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Many patients and their families are hesitant to consult a palliative care (PC) team. In 2014, approximately 6,000,000 people in the United States could benefit from PC, and this number is expected to increase over the next 25 years. OBJECTIVES The purpose of this review is to shed light on the significance of PC and provide a holistic view outlining both the benefits and existing barriers. METHODS A literature search was conducted using MEDLINE (PubMed), Cochrane Central Register of Controlled Trials, and Web of Science to identify articles published in journals from 1948 to 2019. A narrative approach was used to search the grey literature. DISCUSSION Traditionally, the philosophy behind PC was based on alleviating suffering associated with terminal illnesses; PC was recommended only after other treatment options had been exhausted. However, the tenets of PC are applicable to anyone with a life-threatening illness as it is beneficial in conjunction with traditional treatments. It is now recognized that PC services are valuable when initiated alongside disease-modifying therapy early in the disease course. Studies have shown that PC decreased total symptom burden, reduced hospitalizations, and enabled patients to remain safely at home. CONCLUSION As the population ages and chronic illnesses become more widespread, there continues to be a growing need for PC programs. The importance of PC should not be overlooked despite existing barriers such as the lack of professional training and the cost of implementation. Education and open discussion play essential roles in the successful early integration of PC.
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Affiliation(s)
- Helen Senderovich
- Geriatrics & Palliative Care & Pain Medicine, Baycrest Health Sciences, Toronto, Ontario, Canada
- Assistant Professor of the University of Toronto, Department of Family and Community Medicine, Division of Palliative Care, Toronto, Ontario, Canada
- To whom correspondence should be addressed. E-mail:
| | - Kristen McFadyen
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Bicknell R, Lim WK, Maier AB, LoGiuidice D. A study protocol for the development of a multivariable model predicting 6- and 12-month mortality for people with dementia living in residential aged care facilities (RACFs) in Australia. Diagn Progn Res 2020; 4:17. [PMID: 33033746 PMCID: PMC7538167 DOI: 10.1186/s41512-020-00085-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 09/23/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND For residential aged care facility (RACF) residents with dementia, lack of prognostic guidance presents a significant challenge for end of life care planning. In an attempt to address this issue, models have been developed to assess mortality risk for people with advanced dementia, predominantly using long-term care minimum data set (MDS) information from the USA. A limitation of these models is that the information contained within the MDS used for model development was not collected for the purpose of identifying prognostic factors. The models developed using MDS data have had relatively modest ability to discriminate mortality risk and are difficult to apply outside the MDS setting. This study will aim to develop a model to estimate 6- and 12-month mortality risk for people with dementia from prognostic indicators recorded during usual clinical care provided in RACFs in Australia. METHODS A secondary analysis will be conducted for a cohort of people with dementia from RACFs participating in a cluster-randomized trial of a palliative care education intervention (IMPETUS-D). Ten prognostic indicator variables were identified based on a literature review of clinical features associated with increased mortality for people with dementia living in RACFs. Variables will be extracted from RACF files at baseline and mortality measured at 6 and 12 months after baseline data collection. A multivariable logistic regression model will be developed for 6- and 12-month mortality outcome measures using backwards elimination with a fractional polynomial approach for continuous variables. Internal validation will be undertaken using bootstrapping methods. Discrimination of the model for 6- and 12-month mortality will be presented as receiver operating curves with c statistics. Calibration curves will be presented comparing observed and predicted event rates for each decile of risk as well as flexible calibration curves derived using loess-based functions. DISCUSSION The model developed in this study aims to improve clinical assessment of mortality risk for people with dementia living in RACFs in Australia. Further external validation in different populations will be required before the model could be developed into a tool to assist with clinical decision-making in the future.
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Affiliation(s)
- Ross Bicknell
- Department of Medicine and Aged Care, @AgeMelbourne, Melbourne Health–Royal Melbourne Hospital, University of Melbourne, 6 North Main Building, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050 Australia
| | - Wen Kwang Lim
- Department of Medicine and Aged Care, @AgeMelbourne, Melbourne Health–Royal Melbourne Hospital, University of Melbourne, 6 North Main Building, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050 Australia
| | - Andrea B. Maier
- Department of Medicine and Aged Care, @AgeMelbourne, Melbourne Health–Royal Melbourne Hospital, University of Melbourne, 6 North Main Building, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050 Australia
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dina LoGiuidice
- Department of Medicine and Aged Care, @AgeMelbourne, Melbourne Health–Royal Melbourne Hospital, University of Melbourne, 6 North Main Building, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050 Australia
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Usability of the surprise question by nurses to identify 12-month mortality in hospitalized older patients: A prospective cohort study. Int J Nurs Stud 2020; 109:103609. [DOI: 10.1016/j.ijnurstu.2020.103609] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 04/01/2020] [Accepted: 04/12/2020] [Indexed: 11/23/2022]
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118
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Lai CF, Cheng CI, Chang CH, Chen YT, Hwang HC, Lin SL, Huang JW, Huang SJ. Integrating the Surprise Question, Palliative Care Screening Tool, and Clinical Risk Models to Identify Peritoneal Dialysis Patients With High One-Year Mortality. J Pain Symptom Manage 2020; 60:613-621.e6. [PMID: 32278098 DOI: 10.1016/j.jpainsymman.2020.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 01/20/2023]
Abstract
CONTEXT Universal screening to identify vulnerable patients who may receive limited benefits from life-sustaining treatments can facilitate palliative care in dialysis populations. OBJECTIVES We aimed to develop prediction models for one-year mortality in peritoneal dialysis (PD) patients. METHODS This prospective cohort study included 401 adult Taiwanese prevalent PD patients (average age 56.2 ± 14 years). In addition to obtaining clinical characteristics and laboratory data, the primary care nurses evaluated the surprise question (SQ) and palliative care screening tool (PCST) for each patient in March 2015. Multivariate logistic regression models were conducted to predict the primary outcome of one-year all-cause mortality. RESULTS There were 34 (8.5%) patients who died during the first year of follow-up. Patients allocated to the not surprised group according to the SQ and those who received a score of ≥4 on the PCST had increased odds of death (odds ratio 24.68 [95% CI 10.66-57.13] and 12.18 [95% CI 5.66-26.21], respectively). We also developed a clinical risk model for one-year mortality that included sex, dialysis vintage, coronary artery disease, malignancy, normalized protein nitrogen appearance, white blood cell count, and serum albumin and sodium levels. Integrating the SQ, PCST, and clinical risk model exhibited good discrimination with an area under the receiver operating characteristic curve of 0.95. Kaplan-Meier analysis showed worse survival in high-risk patients predicted by the integrated model (log-rank P < 0.001). CONCLUSION Screening with the use of the integrated measurement can identify high-risk PD patients. This approach may facilitate palliative care interventions for at-risk subpopulations.
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Affiliation(s)
- Chun-Fu Lai
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-I Cheng
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Hao Chang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Ting Chen
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsiau-Chien Hwang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuei-Liong Lin
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jenq-Wen Huang
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Sheng-Jean Huang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Taipei City Hospital, Taipei, Taiwan
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119
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Boje J, Madsen JK, Finderup J. Palliative care needs experienced by Danish patients with end-stage kidney disease. J Ren Care 2020; 47:169-183. [PMID: 32865343 DOI: 10.1111/jorc.12347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients with end-stage kidney disease (ESKD) may have palliative care needs. A tool validated in a Danish context to identify such needs is lacking. The Integrated Palliative Outcome Scale-Renal (IPOS-Renal) aims to identify patients' palliative care needs. The current study is the first phase of a research project translating and validating the IPOS-Renal into Danish. OBJECTIVES To investigate palliative care needs among Danish patients with ESKD. DESIGN A literature review was conducted using meta-ethnography inspired by Noblit and Hare. A focus group with health care professionals (HCPs) and semi-structured individual patient interviews were conducted and analysed using Malterud's principles of systematic text condensation. RESULTS A synthesis of 15 studies, a focus group with 13 HCPs, and interviews with nine patients were conducted. We found that patients with ESKD experienced several symptoms related to physical, social, mental and existential and practical needs. The most prominent findings were fatigue, reduced physical functioning, dizziness, impaired memory, dependency on relatives or HCPs, social isolation and loss of identity. CONCLUSION The palliative care needs identified in the Danish patient population are substantiated by the IPOS-Renal questionnaire. However, some Danish patients also appear to struggle with dizziness and impaired memory. These symptoms do not appear specifically in the IPOS-Renal questionnaire but may have to be included in a Danish version.
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Affiliation(s)
- Julie Boje
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University of Denmark, Aarhus, Denmark
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120
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Remawi BN, Gadoud A, Murphy IMJ, Preston N. Palliative care needs-assessment and measurement tools used in patients with heart failure: a systematic mixed-studies review with narrative synthesis. Heart Fail Rev 2020; 26:137-155. [PMID: 32748015 PMCID: PMC7769784 DOI: 10.1007/s10741-020-10011-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Patients with heart failure have comparable illness burden and palliative care needs to those with cancer. However, few of them are offered timely palliative care. One main barrier is the difficulty in identifying those who require palliative care. Several palliative care needs-assessment/measurement tools were used to help identify these patients and assess/measure their needs, but it is not known which one is the most appropriate for this population. This review aimed to identify the most appropriate palliative care needs-assessment/measurement tools for patients with heart failure. Cochrane Library, MEDLINE Complete, AMED, PsycINFO, CINAHL Complete, EMBASE, EThOS, websites of the identified tools, and references and citations of the included studies were searched from inception to 25 June 2020. Studies were included if they evaluated palliative care needs-assessment/measurement tools for heart failure populations in terms of development, psychometrics, or palliative care patient/needs identification. Twenty-seven papers were included regarding nineteen studies, most of which were quantitative and observational. Six tools were identified and compared according to their content and context of use, development, psychometrics, and clinical applications in identifying patients with palliative care needs. Despite limited evidence, the Needs Assessment Tool: Progressive Disease - Heart Failure (NAT:PD-HF) is the most appropriate palliative care needs-assessment tool for use in heart failure populations. It covers most of the patient needs and has the best psychometric properties and evidence of identification ability and appropriateness. Psychometric testing of the tools in patients with heart failure and evaluating the tools to identify those with palliative care needs require more investigation.
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Affiliation(s)
- Bader Nael Remawi
- Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG, UK.
| | - Amy Gadoud
- Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG, UK.,International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG, UK
| | - Iain Malcolm James Murphy
- Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG, UK.,Trinity Hospice and Palliative Care Services, Low Moor Road, Blackpool, FY2 0BG, UK
| | - Nancy Preston
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG, UK
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Scaccabarozzi G, Amodio E, Riva L, Corli O, Maltoni M, Di Silvestre G, Turriziani A, Morino P, Pellegrini G, Crippa M. Clinical Care Conditions and Needs of Palliative Care Patients from Five Italian Regions: Preliminary Data of the DEMETRA Project. Healthcare (Basel) 2020; 8:healthcare8030221. [PMID: 32698477 PMCID: PMC7551071 DOI: 10.3390/healthcare8030221] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 01/03/2023] Open
Abstract
In order to plan the right palliative care for patients and their families, it is essential to have detailed information about patients' needs. To gain insight into these needs, we analyzed five Italian local palliative care networks and assessed the clinical care conditions of patients facing the complexities of advanced and chronic disease. A longitudinal, observational, noninterventional study was carried out in five Italian regions from May 2017 to November 2018. Patients who accessed the palliative care networks were monitored for 12 months. Sociodemographic, clinical, and symptom information was collected with several tools, including the Necesidades Paliativas CCOMS-ICO (NECPAL) tool, the Edmonton Symptom Assessment System (ESAS), and interRAI Palliative Care (interRAI-PC). There were 1013 patients in the study. The majority (51.7%) were recruited at home palliative care units. Cancer was the most frequent diagnosis (85.4%), and most patients had at least one comorbidity (58.8%). Cancer patients reported emotional stress with severe symptoms (38.7% vs. 24.3% in noncancer patients; p = 0.001) and were less likely to have clinical frailty (13.3% vs. 43.9%; p < 0.001). Our study confirms that many patients face the last few months of life with comorbidities or extreme frailty. This study contributes to increasing the general knowledge on palliative care needs in a high-income country.
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Affiliation(s)
| | - Emanuele Amodio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy;
| | - Luca Riva
- UOS Unità Cure Palliative Ospedaliere, ASST Lecco, 23900 Lecco, Italy;
| | - Oscar Corli
- Pain and Palliative Care Research Unit, Istituto di Ricerche Farmacologiche Mario Negri-IRCCS, 20156 Milan, Italy;
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola (FC), Italy;
| | | | - Adriana Turriziani
- Master Cure Palliative, Università Cattolica S.Cuore, 00168 Rome, Italy;
| | - Piero Morino
- UFC Coordinamento Aziendale Cure Palliative USL Toscana Centro, 50142 Firenze, Italy;
| | - Giacomo Pellegrini
- Fondazione Floriani, Via privata Nino Bonnet, 2-20154 Milan, Italy;
- Correspondence: ; Tel.: +39-02-6261-1132
| | - Matteo Crippa
- Fondazione Floriani, Via privata Nino Bonnet, 2-20154 Milan, Italy;
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Lazzarin P, Giacomelli L, Terrenato I, Benini F. A Tool for the Evaluation of Clinical Needs and Eligibility to Pediatric Palliative Care: The Validation of the ACCAPED Scale. J Palliat Med 2020; 24:205-210. [PMID: 32640899 DOI: 10.1089/jpm.2020.0148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Despite their importance, pediatric palliative care (PPC) services are still scantly diffused. In addition, eligibility criteria for PPC are quite complex. Consequently, clinicians require a tool that suggests how to refer patients with life-limiting diseases to the most appropriate service and how to properly allocate health care resources. Objective: Recently, the Accertamento dei bisogni Clinico-Assistenziali Complessi in PEDiatria (ACCAPED) scale has been developed by a group of experts in PPC to evaluate the specific clinical needs of pediatric patients with a life-limiting disease. This study presents the validation of the ACCAPED scale. Design: Validation of ACCAPED scale was pursued by means of description and analysis of clinical vignettes representing patients with challenging-to-evaluate needs who have to be referred to the most appropriate service (community care, general PPC, and specialized PPC). The evaluation of vignettes according to the clinical experience of the experts represented the gold standard against which the validity of the ACCAPED scale was tested by groups with different levels of experience (experts, pediatricians, and health care providers (HCPs) not involved in PPC). Results: Results show a very high concordance between the evaluation of the vignettes through the ACCAPED scale and the evaluation by the clinical experience for experts in PPC and pediatricians. A less favorable grade of concordance has been recorded for HCPs not involved in PPC, suggesting that educational efforts to improve basic knowledge of PPC within the medical community are needed. Conclusions: Overall, this study suggests that the ACCAPED scale is a useful tool to improve rationalization of resources and eligibility criteria for PPC.
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Affiliation(s)
- Pierina Lazzarin
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | - Luca Giacomelli
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Polistudium SRL, Milano, Italy
| | - Irene Terrenato
- Biostatistics and Bioinformatic Unit, Scientific Direction, IRCCS-Regina Elena National Cancer Institute, Rome, Italy
| | - Franca Benini
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
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Burghle A, Lundby C, Ryg J, Søndergaard J, Pottegård A, Nielsen D, Graabæk T. Attitudes Towards Deprescribing Among Older Adults with Limited Life Expectancy and Their Relatives: A Systematic Review. Drugs Aging 2020; 37:503-520. [DOI: 10.1007/s40266-020-00774-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sex-Specific Differences in Hospital Transfers of Nursing Home Residents: Results from the HOspitalizations and eMERgency Department Visits of Nursing Home Residents (HOMERN) Project. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17113915. [PMID: 32492840 PMCID: PMC7312075 DOI: 10.3390/ijerph17113915] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/25/2020] [Accepted: 05/29/2020] [Indexed: 01/04/2023]
Abstract
Nursing home (NH) residents are often transferred to hospital (emergency department (ED) visits or hospital admissions) and this occurs more frequently in males. However, respective reasons are rather unclear. We conducted a multicenter prospective study in 14 northwest German NHs with 802 residents in which NH staff recorded anonymized data between March 2018 and July 2019 for each hospital transfer. Measures were analyzed using descriptive statistics and compared between sexes via univariate logistic regression analyses using mixed models with random effects. Eighty-eight planned transfers (53.5% hospital admissions, 46.5% ED visits) occurred as well as 535 unplanned transfers (63.1% hospital admissions, 36.9% ED visits). The two most common causes for unplanned transfers were deteriorations of health status (35.1%) and falls/accidents/injuries (33.5%). Male transferred residents were younger, more often married; their advance directives were more commonly not considered correctly and the NH staff identified more males nearing the end of life than females (52.9% vs. 38.2%). Only 9.2% of transfers were rated avoidable. For advance directive availability and NH staff’s perceptions on transfer conditions, we found marked inter-facility differences. There might be sociocultural factors influencing hospital transfer decisions of male and female nursing home residents and facility characteristics that may affect transfer policy.
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Yen YF, Lee YL, Hu HY, Sun WJ, Ko MC, Chen CC, Wong WK, Morisky DE, Huang SJ, Chu D. Early palliative care: the surprise question and the palliative care screening tool-better together. BMJ Support Palliat Care 2020; 12:211-217. [PMID: 32451326 DOI: 10.1136/bmjspcare-2019-002116] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 04/05/2020] [Accepted: 04/19/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The 'surprise question' (SQ) and the palliative care screening tool (PCST) are the common assessment tools in the early identification of patients requiring palliative care. However, the comparison of their prognostic accuracies has not been extensively studied. This study aimed to compare the prognostic accuracy of SQ and PCST in terms of recognising patients nearing end of life (EOL) and those appropriate for palliative care. METHODS This prospective study used both the SQ and PCST to predict patients' 12-month mortality and identified those appropriate for palliative care. All adult patients admitted to Taipei City Hospital in 2015 were included in this cohort study. The c-statistic value was calculated to indicate the predictive accuracies of the SQ and PCST. RESULTS Out of 21 109 patients, with a mean age of 62.8 years, 12.4% and 11.1% had a SQ response of 'no' and a PCST score of ≥4, respectively. After controlling for other covariates, an SQ response of 'no' and a PCST score of ≥4 were the independent predictors of 12-month mortality. The c-statistic values of the SQ and PCST at recognising patients in their last year of life were 0.680 and 0.689, respectively. When using a combination of both SQ and PCST in predicting patients' 12-month mortality risk, the predictive value of the c-statistic increased to 0.739 and was significantly higher than either one in isolation (p<0.001). CONCLUSION A combination of the SQ with PCST has better prognostic accuracy than either one in isolation.
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Affiliation(s)
- Yung-Feng Yen
- Section of Infectious Diseases, Taipei City Hospital Yangming Branch, Taipei, Taiwan
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Ya-Ling Lee
- Department of Dentistry, Taipei City Hospital, Taipei, Taiwan
- Department of Dentistry, School of Dentistry, National Yang-Ming University, Taipei, Taiwan
| | - Hsiao-Yun Hu
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
- Department of Education and Research, Taipei City Hospital, Taipei, Taiwan
| | - Wen-Jung Sun
- Community Medicine Department & Family Medicine Division, Taipei City Hospital Zhongxing Branch, Taipei, Taiwan
| | - Ming-Chung Ko
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
- Department of Urology, Taipei City Hospital, Taipei, Taiwan
| | - Chu-Chieh Chen
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Weng Kee Wong
- Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Donald E Morisky
- Department of Community Health Sciences, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Sheng-Jean Huang
- Department of Neurosurgery, Taipei City Hospital, Taipei, Taiwan
- Department of Surgery, Medical College, National Taiwan University Hospital, Taipei, Taiwan
| | - Dachen Chu
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Taipei City Hospital, Taipei, Taiwan
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Zeeh J, Memm K, Heppner HJ, Kwetkat A. [Covid-19 pandemic. Mechanical ventilation in geriatric patients - an ethical dilemma?]. MMW Fortschr Med 2020; 162:40-45. [PMID: 32405841 PMCID: PMC7220539 DOI: 10.1007/s15006-020-0475-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Dieser Beitrag möchte einen Überblick darüber geben, wie und mit Hilfe welcher Kriterien eine medizinisch, ethisch und rechtlich vertretbare Entscheidung darüber getroffen werden kann, welche der betagten Patienten mit einer schweren COVID-19-Pneumonie mittels künstlicher Beatmung behandelt werden sollten und welche von einer solchen Therapie eher nicht profitieren würden.
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Affiliation(s)
- Joachim Zeeh
- Abteilung Hospiz- und Palliativversorgung, Sozialwerk Meiningen gGmbH, Ernststraße 7, D-98617 Meiningen, Deutschland
| | - Kristin Memm
- Kanzlei für Medizinrecht/Medizinethik/Digitale Medizin, Wiesenbach 11, D-99097 Erfurt, Deutschland
| | - Hans-Jürgen Heppner
- HELIOS Klinikum Schwelm, Dr.-Moeller-Straße 15, D-58332 Schwelm, Deutschland
| | - Anja Kwetkat
- Universitätsklinikum Jena, Bachstraße 18, D-07743 Jena, Deutschland
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Nickel CH, Kellett J, Nieves Ortega R, Lyngholm L, Hanson S, Cooksley T, Bingisser R, Brabrand M. A simple prognostic score predicts one-year mortality of alert and calm emergency department patients: A prospective two-center observational study. Int J Clin Pract 2020; 74:e13481. [PMID: 31985868 DOI: 10.1111/ijcp.13481] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/02/2020] [Accepted: 01/21/2020] [Indexed: 12/28/2022] Open
Abstract
STUDY OBJECTIVE To derive and validate a prognostic score to predict 1-year mortality using vital signs, mobility and other variables that are readily available at the bedside at no additional cost. METHODS Post hoc analysis of two independent prospective observational studies in two emergency departments, one in Denmark and the other in Switzerland. PARTICIPANTS Alert and calm emergency department patients. MEASUREMENTS The prediction of mortality from presentation to 365 days by vital signs, mobility and other variables that are readily available at the bedside at no additional cost. RESULTS One thousand six hundred and eighteen alert and calm patients were in the Danish cohort and 1331 in the Swiss cohort. Logistic regression identified age >68 years, abnormal vital signs, impaired mobility and the decision to admit as significant predictors of 365-day mortality. A simple prognostic score awarded one point to each of these predictors. Less than two of these predictors were present in 45.6% of patients, and only 0.4% of these patients died within a year. If two or more of these predictors were present, 365-day mortality increased exponentially. CONCLUSION Age >68 years, the decision for hospital admission, any vital sign abnormality at presentation and impaired mobility at presentation are equally powerful predictors of 1-year mortality in alert and calm emergency department patients. If validated by others these predictors could be used to discharge patients with confidence since nearly half of these patients had less than two predictors and none of them died within 30 days. However, when two or more predictors were present 365-day mortality increased exponentially.
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Affiliation(s)
| | - John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | | | - Le Lyngholm
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - Stine Hanson
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - Tim Cooksley
- Department of Acute Medicine, University Hospital of South Manchester, Manchester, UK
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Mikkel Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
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Schifeling CH, Fischer SM. Missing the Mark: High Rates of Absent and Untimely Access to Specialty Palliative Care in Patients with Peri-Hospital Mortality. J Palliat Med 2020; 23:1485-1492. [PMID: 32282253 DOI: 10.1089/jpm.2019.0628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Despite mounting evidence that specialty palliative care (PC) improves patients' symptoms, quality of life, and goal concordant care, these services are likely underutilized. Objective: To determine the rate of missed and delayed opportunities for specialty PC in patients with peri-hospital death. Design: A retrospective, cross-sectional analysis, using electronic medical records of a state-wide healthcare system in Colorado, was performed. Included were adults who died during admission or within seven days of discharge from January 2015 to October 2018 at an academic medical center and had prior encounters within the affiliated state-wide healthcare system in the last year of life. Excluded were patients with sudden or obstetrics-related deaths. Referral orders from the electronic medical record identified specialty PC consultation. Data from the Colorado Department of Public Health and Environment linked with the medical record determined time from first PC consultation to death. Results: The sample included 2088 decedent patients, with most deaths (81%) occurring in the hospital. Only 33% of patients had PC consultation, which was higher for patients with cancer (42%) than for those without cancer (26%). Of patients with specialty PC consultation, the median time from first referral to death was eight days (interquartile range: 3.25-25 days). Conclusions: Patients with peri-hospital death have low rates of specialty PC consultation, which, when present, often occurs close to death. This suggests there is a high rate of missed opportunities for specialty PC in this population.
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Affiliation(s)
- Christopher H Schifeling
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Stacy M Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Puente-Fernández D, Roldán-López CB, Campos-Calderón CP, Hueso-Montoro C, García-Caro MP, Montoya-Juarez R. Prospective Evaluation of Intensity of Symptoms, Therapeutic Procedures and Treatment in Palliative Care Patients in Nursing Homes. J Clin Med 2020; 9:jcm9030750. [PMID: 32164342 PMCID: PMC7141278 DOI: 10.3390/jcm9030750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 02/04/2023] Open
Abstract
The aim of the study is to evaluate the intensity of symptoms, and any treatment and therapeutic procedures received by advanced chronic patients in nursing homes. A multi-centre prospective study was conducted in six nursing homes for five months. A nurse trainer selected palliative care patients from whom the sample was randomly selected for inclusion. The Edmonton Symptoms Assessment Scale, therapeutic procedures, and treatment were evaluated. Parametric and non-parametric tests were used to evaluate month-to-month differences and differences between those who died and those who did not. A total of 107 residents were evaluated. At the end of the follow-up, 39 had (34.6%) died. All symptoms (p < 0.050) increased in intensity in the last week of life. Symptoms were more intense in those who had died at follow-up (p < 0.05). The use of aerosol sprays (p = 0.008), oxygen therapy (p < 0.001), opioids (p < 0.001), antibiotics (p = 0.004), and bronchodilators (p = 0.003) increased in the last week of life. Peripheral venous catheters (p = 0.022), corticoids (p = 0.007), antiemetics (p < 0.001), and antidepressants (p < 0.05) were used more in the patients who died. In conclusion, the use of therapeutic procedures (such as urinary catheters, peripheral venous catheter placement, and enteral feeding) and drugs (such as antibiotics, anxiolytics, and new antidepressant prescriptions) should be carefully considered in this clinical setting.
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Affiliation(s)
- Daniel Puente-Fernández
- Doctoral Program of Clinical Medicine and Public Health, University of Granada, 18071 Granada, Spain;
| | - Concepción B. Roldán-López
- Department of Statistics and Operational Research, Faculty of Medicine, University of Granada, 1016 Granada, Spain;
| | | | - Cesar Hueso-Montoro
- Department of Nursing, Faculty of Health Sciences, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Spain; (C.H.-M.); (M.P.G.-C.); (R.M.-J.)
| | - María P. García-Caro
- Department of Nursing, Faculty of Health Sciences, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Spain; (C.H.-M.); (M.P.G.-C.); (R.M.-J.)
| | - Rafael Montoya-Juarez
- Department of Nursing, Faculty of Health Sciences, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Spain; (C.H.-M.); (M.P.G.-C.); (R.M.-J.)
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Sganga F, Barillaro C, Tamburrano A, Nicolotti N, Cambieri A, Bernabei R, Turriziani A. The benefits of a hospital palliative care team. Int J Palliat Nurs 2020; 25:345-352. [PMID: 31339820 DOI: 10.12968/ijpn.2019.25.7.345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To investigate the association between a hospital palliative care unit assessment and hospital outcome. METHODS This was a prospective cohort study. Data were assessed from all patients treated and followed by the hospital palliative care team (HPCT) from November 2016 until December 2017. RESULTS The mean age of the 588 patients was 73.15±13.6 years. All of the patients included in the study were referred to palliative care. A large proportion of patients were affected by cancer, 69.7% (410), while 30.3% (178) were affected by an advanced chronic illness. The three most frequent cancers were: gastrointestinal (n=81, 19.8%), gynaecological (n=66, 16.1%) and lung (n=63, 15.4%); the three most frequent chronic advanced diseases were: advanced dementia (n=45, 25.3%), severe ischaemic/haemorrhagic stroke (n=36, 20.2%) and severe heart failure (n=25, 15.3%). The majority of patients were in clinical wards (n=476, 81.0%) and the average length of stay was 22.9 days. Hospital outcome trends were evaluated in terms of length of stay and number of deaths that occurred in the hospital. In particular, length of stay decreased from 25.8 days to 18.1 days, hospital death from 13 to 0 during the time that the HPCT assessed patients for an appropriate discharge. CONCLUSION The HPCT is an effective means of managing patients affected by severe illness, reducing the number of deaths that occur within the hospital, long periods of hospitalisation and instances of readmission. However, further studies are required to fully assess the impact of an HPCT on hospital outcomes.
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Affiliation(s)
- Federica Sganga
- Consultant Geriatrician, U.O.S.A. Cure Palliative-Centrale di Continuità Assistenziale, Department of Geriatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Christian Barillaro
- Geriatrician, U.O.S.A. Cure Palliative-Centrale di Continuità Assistenziale, Department of Geriatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Andrea Tamburrano
- Resident Doctor, Section of Hygiene-Institute of Public Health, Università Cattolica del Sacro Cuore and Medical Management, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Nicola Nicolotti
- Public Health and Preventive Medicine Specialist, Medical Management-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Andrea Cambieri
- Hospital Administrator Medical Doctor, Medical Management-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Roberto Bernabei
- Geriatrician, Director, Department of Geriatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Adriana Turriziani
- Radiotherapist-Palliative Care Doctor, U.O.S.A. Cure Palliative-Centrale di Continuità Assistenziale, Department of Geriatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
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Design and implementation of a clinical decision support tool for primary palliative Care for Emergency Medicine (PRIM-ER). BMC Med Inform Decis Mak 2020; 20:13. [PMID: 31992301 PMCID: PMC6988238 DOI: 10.1186/s12911-020-1021-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 01/13/2020] [Indexed: 12/04/2022] Open
Abstract
Background The emergency department is a critical juncture in the trajectory of care of patients with serious, life-limiting illness. Implementation of a clinical decision support (CDS) tool automates identification of older adults who may benefit from palliative care instead of relying upon providers to identify such patients, thus improving quality of care by assisting providers with adhering to guidelines. The Primary Palliative Care for Emergency Medicine (PRIM-ER) study aims to optimize the use of the electronic health record by creating a CDS tool to identify high risk patients most likely to benefit from primary palliative care and provide point-of-care clinical recommendations. Methods A clinical decision support tool entitled Emergency Department Supportive Care Clinical Decision Support (Support-ED) was developed as part of an institutionally-sponsored value based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health. A multidisciplinary approach was used to develop Support-ED including: a scoping review of ED palliative care screening tools; launch of a workgroup to identify patient screening criteria and appropriate referral services; initial design and usability testing via the standard System Usability Scale questionnaire, education of the ED workforce on the Support-ED background, purpose and use, and; creation of a dashboard for monitoring and feedback. Results The scoping review identified the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a validated instrument in which to adapt and apply for the creation of the CDS tool. The multidisciplinary workshops identified two primary objectives of the CDS: to identify patients with indicators of serious life limiting illness, and to assist with referrals to services such as palliative care or social work. Additionally, the iterative design process yielded three specific patient scenarios that trigger a clinical alert to fire, including: 1) when an advance care planning document was present, 2) when a patient had a previous disposition to hospice, and 3) when historical and/or current clinical data points identify a serious life-limiting illness without an advance care planning document present. Monitoring and feedback indicated a need for several modifications to improve CDS functionality. Conclusions CDS can be an effective tool in the implementation of primary palliative care quality improvement best practices. Health systems should thoughtfully consider tailoring their CDSs in order to adapt to their unique workflows and environments. The findings of this research can assist health systems in effectively integrating a primary palliative care CDS system seamlessly into their processes of care. Trial registration ClinicalTrials.gov Identifier: NCT03424109. Registered 6 February 2018, Grant Number: AT009844–01.
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Chu C, Anderson R, White N, Stone P. Prognosticating for Adult Patients With Advanced Incurable Cancer: a Needed Oncologist Skill. Curr Treat Options Oncol 2020; 21:5. [PMID: 31950387 PMCID: PMC6965075 DOI: 10.1007/s11864-019-0698-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with advanced cancer and their families commonly seek information about prognosis to aid decision-making in medical (e.g. surrounding treatment), psychological (e.g. saying goodbye), and social (e.g. getting affairs in order) domains. Oncologists therefore have a responsibility to identify and address these requests by formulating and sensitively communicating information about prognosis. Current evidence suggests that clinician predictions are correlated with actual survival but tend to be overestimations. In an attempt to cultivate prognostic skills, it is recommended that clinicians practice formulating and recording subjective estimates of prognosis in advanced cancer patient’s medical notes. When possible, a multi-professional prognostic estimate should be sought as these may be more accurate than individual predictions alone. Clinicians may consider auditing the accuracy of their predictions periodically and using feedback from this process to improve their prognostic skills. Clinicians may also consider using validated prognostic tools to complement their clinical judgements. However, there is currently only limited evidence about the comparative accuracy of different prognostic tools or the extent to which these measures are superior to clinical judgement. Oncologists and palliative care physicians should ensure that they receive adequate training in advanced communication skills, which builds upon their pre-existing skills, to sensitively deliver information on prognosis. In particular, clinicians should acknowledge their own prognostic uncertainty and should emphasise the supportive care that can continue to be provided after stopping cancer-directed therapies.
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Affiliation(s)
- Christina Chu
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Rebecca Anderson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
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Veldhoven CMM, Nutma N, De Graaf W, Schers H, Verhagen CAHHVM, Vissers KCP, Engels Y. Screening with the double surprise question to predict deterioration and death: an explorative study. BMC Palliat Care 2019; 18:118. [PMID: 31881958 PMCID: PMC6935168 DOI: 10.1186/s12904-019-0503-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 12/09/2019] [Indexed: 12/25/2022] Open
Abstract
Background Early identification of palliative patients is challenging. The Surprise Question (SQ1; Would I be surprised if this patient were to die within 12 months?) is widely used to identify palliative patients. However, its predictive value is low. Therefore, we added a second question (SQ2) to SQ1: ‘Would I be surprised if this patient is still alive after 12 months?’ We studied the accuracy of this double surprise question (DSQ) in a general practice. Methods We performed a prospective cohort study with retrospective medical record review in a general practice in the eastern part of the Netherlands. Two general practitioners (GPs) answered both questions for all 292 patients aged ≥75 years (mean age 84 years). Primary outcome was 1-year death, secondary outcomes were aspects of palliative care. Results SQ1 was answered with ‘no‘ for 161/292 patients. Of these, SQ2 was answered with ‘yes’ in 22 patients. Within 12 months 26 patients died, of whom 24 had been identified with SQ1 (sensitivity: 92%, specificity: 49%). Ten of them were also identified with SQ2 (sensitivity: 42%, specificity: 91%). The latter group had more contacts with their GP and more palliative care aspects were discussed. Conclusions The DSQ appears a feasible and easy applicable screening tool in general practice. It is highly effective in predicting patients in high need for palliative care and using it helps to discriminate between patients with different life expectancies and palliative care needs. Further research is necessary to confirm the findings of this study.
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Affiliation(s)
- C M M Veldhoven
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands. .,General practice Berg en Dal, Oude Kleefsebaan 96, 6571, BJ, Berg en Dal, the Netherlands.
| | - N Nutma
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - W De Graaf
- General practice Berg en Dal, Oude Kleefsebaan 96, 6571, BJ, Berg en Dal, the Netherlands
| | - H Schers
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - C A H H V M Verhagen
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - K C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Y Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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Verhoef MJ, de Nijs EJM, Fiocco M, Heringhaus C, Horeweg N, van der Linden YM. Surprise Question and Performance Status Indicate Urgency of Palliative Care Needs in Patients with Advanced Cancer at the Emergency Department: An Observational Cohort Study. J Palliat Med 2019; 23:801-808. [PMID: 31880489 DOI: 10.1089/jpm.2019.0413] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: The surprise question (SQ), "Would I be surprised if this patient died within one year?", is a simple instrument to identify patients with palliative care needs. The SQ-performance has not been evaluated in patients with advanced cancer visiting the emergency department (ED). Objective: To evaluate SQ's test characteristics and predictive value in patients with advanced cancer visiting the ED. Design: Observational cohort study. Setting: Patients >18 years with advanced cancer in the palliative phase visiting the ED of an academic medical center. Methods: Attending physicians answered the SQ (not surprised [NS] or surprised [S]) and estimated Eastern Cooperative Oncology Group (ECOG)-performance status. Disease, visit, and follow-up characteristics were retrospectively collected from charts. SQ's sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and Harrell's c-index were calculated. Prognostic values of SQ and other variables were assessed by using Cox proportional hazards models. Results: Two-hundred-and-forty-five patients were included (203 NS [83%] and 42 S [17%]), median age 62 years, 48% male. Follow-up on overall survival was updated until February 2019. At ED entry, NS-patients had worse ECOG-performance and more symptoms. At study closure, 233 patients had died (95%). Median survival was three months for NS-patients (interquartile [IQ]-range: 1-8); nine months for S-patients (IQ-range: 3-28) (p < 0.0001). SQ-performance for one-year mortality: sensitivity 89%, specificity 40%, PPV 85%, NPV 50%, c-index 0.56, and hazard ratio 2.1 for approaching death. ECOG 3-4 predicted death in NS-patients; addition to the SQ improved c-index (0.65); sensitivity (40%), specificity (92%), PPV (95%), and NPV (29%). Conclusions: At the ED, the SQ plus ECOG 3-4 helps identifying patients with advanced cancer and a limited life expectancy. Its use supports initiating appropriate care related to urgency of palliative care needs.
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Affiliation(s)
- Mary-Joanne Verhoef
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Ellen J M de Nijs
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Marta Fiocco
- Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.,Mathematical Institute, Leiden University, Leiden, the Netherlands
| | - Christian Heringhaus
- Department of Emergency Medicine and Leiden University Medical Center, Leiden, the Netherlands
| | - Nanda Horeweg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Yvette M van der Linden
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, the Netherlands.,Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
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136
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Sullivan SS, Casucci S, Li CS. Eliminating the Surprise Question Leaves Home Care Providers With Few Options for Identifying Mortality Risk. Am J Hosp Palliat Care 2019; 37:542-548. [PMID: 31808348 DOI: 10.1177/1049909119892830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Precision health initiatives for end-of-life planning require robust methods for identifying patient risk for decline and mortality. The Outcome and Assessment Information Set (OASIS) surprise question (SQ; M1034 Overall Status) is the primary tool for evaluating risks in homebound older adults. However, the OASIS-D, Released in 2019, eliminates this question. This study examines the prognostic ability of 12- and 24-month mortality risk reflected in the OASIS-SQ and develops an alternative approach for classifying mortality risk to support decision-making in the absence of the OASIS-SQ. DESIGN Retrospective secondary data analysis. SETTING/PARTICIPANTS A nationally representative sample of 69 097 OASIS-C assessments (2012) linked to the Master Beneficiary Summary file (2012 and 2013). MEASUREMENTS Survival analysis, k-means clustering, and Cohen κ coefficient with Z test. RESULTS The OASIS-SQ predicts mortality (35% at 12 and 45% at 24 months; P < .001). Cluster analysis identified 2 risk groups: OASIS activity of daily living "ADL total scores" >15 = (lower risk) and ≤15 = (higher risk) for 24-month mortality. Model agreement is weak for both cluster 1 and cluster 2, the OASIS-SQ κ = 0.20, 95% confidence interval (CI) = .19 to .21, and "alive/not alive" κ = .17, 95% CI = .16 to .18. CONCLUSION The OASIS-SQ and "ADL total score" are almost equally likely to predict 24-month mortality; therefore, it was reasonable to use the "ADL total score" as a substitute for the OASIS-SQ. Removal of the OASIS-SQ leaves home care providers with few clear options for risk screening resulting in missed opportunities to refer to palliative or hospice services.
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Affiliation(s)
- Suzanne S Sullivan
- School of Nursing, University at Buffalo, State University of New York, NY, USA
| | - Sabrina Casucci
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York, NY, USA
| | - Chin-Shang Li
- School of Nursing, University at Buffalo, State University of New York, NY, USA
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137
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Nyatanga B. Is the surprise question a useful predictive measure of mortality? Int J Palliat Nurs 2019; 25:575. [DOI: 10.12968/ijpn.2019.25.12.575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Brian Nyatanga
- Consultant Editor, Senior Lecturer, University of Worcester
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138
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Elyn A, Sourdet S, Morin L, Nourhashemi F, Saffon N, de Souto Barreto P, Rolland Y. End of life care practice and symptom management outcomes of nursing home residents with dementia: secondary analyses of IQUARE trial. Eur Geriatr Med 2019; 10:947-955. [PMID: 34652768 DOI: 10.1007/s41999-019-00234-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/29/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE End-of-life care is a central issue in nursing homes. Poor care outcomes have been reported, especially among residents with dementia. Our aim was two-fold: to assess whether the diagnosis of dementia was associated with specific patterns of care and symptom management for residents with dementia during the last 6 months of life, and to compare these patterns of care between residents with dementia who died within 6 months and those who survived longer. METHODS Secondary prospective analyses of the IQUARE trial (trial registration number NCT01703689). 175 nursing homes in South West France. Residents with and without dementia at baseline (May-June 2011), stratified according to their vital status at 6-month follow-up. RESULTS Of 6275 residents enrolled in IQUARE study (including 2688 with dementia), 494 (7.9%) died within 6 months. Compared to residents without dementia (n = 254), those with dementia (n = 240) were less likely to be self-sufficient (OR = 0.08, 95% CI 0.01-0.64). They were more likely to have physical restraints (OR = 1.65, 95% CI 1.08-2.51) and less likely to be prescribed benzodiazepines (OR = 0.58, 95% CI 0.38-0.88). Among residents with dementia, those who died during the first 6 months of follow-up were more likely to be identified with a formal "end-of-life" status (OR = 5.71, 95% CI 3.48-9.37) although such identification remains low with only 15% of them. They were more likely to experience pain (OR = 1.43, 95% CI 1.04-1.97) and to be physically restrained (OR = 1.46, 95% CI 1.08-1.98). However, pain relief and psychological distress management were not improved. CONCLUSIONS Poor quality indicators such as physical restraints are associated with end-of-life care for residents with dementia. Among symptom management outcomes, pain medication remains low even if pain complaint increased at life end.
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Affiliation(s)
- Antoine Elyn
- Palliative Care Unit "Résonance", University Hospital of Toulouse, Place du Docteur Baylac, TSA 40031, 31059, Toulouse Cedex 9, France.
| | - Sandrine Sourdet
- Frailty Hospital, Gerontology and Internal Medicine, University Hospital of Toulouse, Cité de la santé, 20, Rue du Pont Saint-Pierre, TSA 60033, 31059, Toulouse Cedex 9, France.,INSERM, URM1027 "Aging and Alzheimer Disease: From Observation to Intervention", Faculté de Médecine, 37 Allées Jules Guesde, 31000, Toulouse, France
| | - Lucas Morin
- Aging Research Centre, Karolinska Institutet and Stockholm University, Gävlegatan 16-113, 30, Stockholm, Sweden
| | - Fati Nourhashemi
- INSERM, URM1027 "Aging and Alzheimer Disease: From Observation to Intervention", Faculté de Médecine, 37 Allées Jules Guesde, 31000, Toulouse, France.,Gerontology and Internal Medicine, University Hospital of Toulouse, Cité de la santé, 20, Rue du Pont Saint-Pierre, TSA 60033, 31059, Toulouse Cedex 9, France
| | - Nicolas Saffon
- Palliative Care Unit "Résonance", University Hospital of Toulouse, Place du Docteur Baylac, TSA 40031, 31059, Toulouse Cedex 9, France
| | - Philipe de Souto Barreto
- INSERM, URM1027 "Aging and Alzheimer Disease: From Observation to Intervention", Faculté de Médecine, 37 Allées Jules Guesde, 31000, Toulouse, France
| | - Yves Rolland
- INSERM, URM1027 "Aging and Alzheimer Disease: From Observation to Intervention", Faculté de Médecine, 37 Allées Jules Guesde, 31000, Toulouse, France.,Gerontology and Internal Medicine, University Hospital of Toulouse, Cité de la santé, 20, Rue du Pont Saint-Pierre, TSA 60033, 31059, Toulouse Cedex 9, France
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139
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Oral health status as predictor of 1-year mortality after discharge from an acute geriatric unit. Eur Geriatr Med 2019; 10:889-897. [DOI: 10.1007/s41999-019-00248-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
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140
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Pocock LV, Wye L, French LRM, Purdy S. Barriers to GPs identifying patients at the end-of-life and discussions about their care: a qualitative study. Fam Pract 2019; 36:639-643. [PMID: 30649266 DOI: 10.1093/fampra/cmy135] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Identification of patients at the end-of-life is the first step in care planning and many general practices have Palliative Care Registers. There is evidence that these largely comprise patients with cancer diagnoses, but little is known about the identification process. OBJECTIVE To explore the barriers that hinder GPs from identifying and registering patients on Palliative Care Registers. METHODS An exploratory qualitative approach was undertaken using semi-structured interviews with GPs in South West England. GPs were asked about their experiences of identifying, registering and discussing end-of-life care with patients. Interviews were audio recorded, transcribed and analysed thematically. RESULTS Most practices had a Palliative Care Register, which were mainly composed of patients with cancer. They reported identifying non-malignant patients at the end-of-life as challenging and were reluctant to include frail or elderly patients due to resource implications. GPs described rarely using prognostication tools to identify patients and conveyed that poor communication between secondary and primary care made prognostication difficult. GPs also detailed challenges around talking to patients about end-of-life care. CONCLUSIONS Palliative Care Registers are widely used by GPs for patients with malignant diagnoses, but seldom for other patients. The findings from our study suggest that this arises because GPs find prognosticating for patients with non-malignant disease more challenging. GPs would value better communication from secondary care, tools for prognostication and training in speaking with patients at the end-of-life enabling them to better identify non-malignant patients at the end-of-life.
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Affiliation(s)
- Lucy V Pocock
- Centre for Academic Primary Care, University of Bristol, UK
| | - Lesley Wye
- Centre for Academic Primary Care, University of Bristol, UK
| | | | - Sarah Purdy
- Centre for Academic Primary Care, University of Bristol, UK
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141
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Almack K. Uncertain trajectories in old age and implications for families and for palliative and end of life care policy and practice. DEATH STUDIES 2019; 45:563-572. [PMID: 31578936 DOI: 10.1080/07481187.2019.1671539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The provision of high-quality end-of-life care for all is high on national (and international) agendas, but areas of unmet needs identified includes elderly people. This article draws on an autoethnographic account of the dying and death of my father to identify and interrogate disjunctions between end-of-life care policy and commonplace experiences of elderly people who die in a hospital setting. There are significant disjunctions between the "blunt" tools of end-of-life care policy and the everyday experiences of the dying and death of an elderly patient and an urgent need to improve end-of-life care for our oldest generations.
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Affiliation(s)
- Kathryn Almack
- School of Health and Social Work, Centre for Research in Public Health and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK
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142
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Dillen K, Ebke M, Koch A, Becker I, Ostgathe C, Voltz R, Golla H. Validation of a palliative care outcome measurement tool supplemented by neurological symptoms (HOPE+): Identification of palliative concerns of neurological patients. Palliat Med 2019; 33:1221-1231. [PMID: 31280657 DOI: 10.1177/0269216319861927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND There is growing interest to integrate palliative care and its structures into the care of neurological patients. However, in Germany there is no comprehensive assessment tool capturing the symptoms of patients with advanced neurological diseases. AIM To validate a newly developed palliative care measurement tool based on an extension of the validated core documentation system Hospice and Palliative Care Evaluation considering additional neurological issues (HOPE+). DESIGN Prospective, observational study using HOPE+ and as external criteria, the Eastern Cooperative Oncology Group (ECOG) performance status and the 12 months "surprise" question (12-SQ) in a neurological population, and assessment for its construct validity and diagnostic accuracy. SETTING/PARTICIPANTS All newly admitted patients to the Department of Neurorehabilitation, Dr. Becker Rhein-Sieg-Clinic aged 18-100 years (#DRKS00010947). RESULTS Data from 263 patients (63 ± 14 years of age) were analyzed. HOPE+ revealed a moderately correlated six-factor structure (r = -0.543-0.525). Correlation analysis to evaluate discriminant validity using ECOG as external criterion was high (rs(261) = 0.724, p < 0.001) and confirmed for severely affected patients by adding the 12-SQ ("No"-group: 48.00 ± 14.92 vs "Yes"-group: 18.67 ± 7.57, p < 0.009). Operating characteristics show satisfactory diagnostic accuracy (area under the curve: 0.746 ± 0.049, 95% confidence interval = 0.650-0.842). CONCLUSION HOPE+ demonstrates promising psychometric properties. It helps to assess palliative care issues of patients in neurological settings and, in combination with the 12-SQ, conceivably conditions when to initiate the palliative care approach in a population underrepresented in palliative care structures so far.
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Affiliation(s)
- Kim Dillen
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Markus Ebke
- Neurological Centre for Rehabilitation-MEDIAN-Clinics, Bad Salzuflen, Germany.,Dr. Becker Rhein Sieg Clinic, Nümbrecht, Germany
| | - Andreas Koch
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Ingrid Becker
- Institute of Medical Statistics and Computational Biology (IMSB), Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,Center for Integrated Oncology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,Center for Clinical Trials, University of Cologne, Cologne, Germany.,Center for Health Services Research (ZVFK), Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,Center for Integrated Oncology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
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143
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Abstract
Shared decision making requires the exchange of information from the patient and the surgeon (and ideally involves the expertise of the entire multidisciplinary team) to determine the medical and/or surgical treatment that best aligns with the patient's goals and values. Should the surgical patient wish to transition to end-of-life care, the transition to comfort-focused care is within the scope of practice for surgeons. Incorporating the expertise of other health care professionals is an important consideration for whole-patient care. Integrating primary palliative care into surgical practice can help mitigate unnecessary suffering and allow a smoother transition to comfort-focused care.
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Affiliation(s)
- Christine C Toevs
- Terre Haute Regional Hospital, 3901 South 7th Street, Terre Haute, IN 47802, USA; Indiana University School of Medicine, Terre Haute, IN, USA.
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144
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Anderson RT, Cleek H, Pajouhi AS, Bellolio MF, Mayukha A, Hart A, Hickson LJ, Feely MA, Wilson ME, Giddings Connolly RM, Erwin PJ, Majzoub AM, Tangri N, Thorsteinsdottir B. Prediction of Risk of Death for Patients Starting Dialysis: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol 2019; 14:1213-1227. [PMID: 31362990 PMCID: PMC6682819 DOI: 10.2215/cjn.00050119] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 06/11/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Dialysis is a preference-sensitive decision where prognosis may play an important role. Although patients desire risk prediction, nephrologists are wary of sharing this information. We reviewed the performance of prognostic indices for patients starting dialysis to facilitate bedside translation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Systematic review and meta-analysis following the PRISMA guidelines. We searched Ovid MEDLINE, Ovid Embase, Ovid Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus for eligible studies of patients starting dialysis published from inception to December 31, 2018. SELECTION CRITERIA Articles describing validated prognostic indices predicting mortality at the start of dialysis. We excluded studies limited to prevalent dialysis patients, AKI and studies excluding mortality in the first 1-3 months. Two reviewers independently screened abstracts, performed full text assessment of inclusion criteria and extracted: study design, setting, population demographics, index performance and risk of bias. Pre-planned random effects meta-analysis was performed stratified by index and predictive window to reduce heterogeneity. RESULTS Of 12,132 articles screened and 214 reviewed in full text, 36 studies were included describing 32 prognostic indices. Predictive windows ranged from 3 months to 10 years, cohort sizes from 46 to 52,796. Meta-analysis showed discrimination area under the curve (AUC) of 0.71 (95% confidence interval, 0.69 to 073) with high heterogeneity (I2=99.12). Meta-analysis by index showed highest AUC for The Obi, Ivory, and Charlson comorbidity index (CCI)=0.74, also CCI was the most commonly used (ten studies). Other commonly used indices were Kahn-Wright index (eight studies, AUC 0.68), Hemmelgarn modification of the CCI (six studies, AUC 0.66) and REIN index (five studies, AUC 0.69). Of the indices, ten have been validated externally, 16 internally and nine were pre-existing validated indices. Limitations include heterogeneity and exclusion of large cohort studies in prevalent patients. CONCLUSIONS Several well validated indices with good discrimination are available for predicting survival at dialysis start.
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Affiliation(s)
| | | | | | | | | | - Allyson Hart
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Hennepin County Medical Center, Minneapolis, Minnesota
| | - LaTonya J. Hickson
- Division of Nephrology and Hypertension
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery
| | | | - Michael E. Wilson
- Biomedical Ethics Program
- Division of Pulmonary and Critical Care Medicine, and
| | | | | | | | - Navdeep Tangri
- Department of Medicine and
- Department of Community Health Sciences, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Canada
| | - Bjorg Thorsteinsdottir
- Biomedical Ethics Program
- Division of Community Internal Medicine
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery
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145
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Prioritizing Primary Care Patients for a Communication Intervention Using the "Surprise Question": a Prospective Cohort Study. J Gen Intern Med 2019; 34:1467-1474. [PMID: 31190257 PMCID: PMC6667512 DOI: 10.1007/s11606-019-05094-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/11/2018] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Communication about priorities and goals improves the value of care for patients with serious illnesses. Resource constraints necessitate targeting interventions to patients who need them most. OBJECTIVE To evaluate the effectiveness of a clinician screening tool to identify patients for a communication intervention. DESIGN Prospective cohort study. SETTING Primary care clinics in Boston, MA. PARTICIPANTS Primary care physicians (PCPs) and nurse care coordinators (RNCCs) identified patients at high risk of dying by answering the Surprise Question (SQ): "Would you be surprised if this patient died in the next 2 years?" MEASUREMENTS Performance of the SQ for predicting mortality, measured by the area under receiver operating curve (AUC), sensitivity, specificity, and likelihood ratios. RESULTS Sensitivity of PCP response to the SQ at 2 years was 79.4% and specificity 68.6%; for RNCCs, sensitivity was 52.6% and specificity 80.6%. In univariate regression, the odds of 2-year mortality for patients identified as high risk by PCPs were 8.4 times higher than those predicted to be at low risk (95% CI 5.7-12.4, AUC 0.74) and 4.6 for RNCCs (3.4-6.2, AUC 0.67). In multivariate analysis, both PCP and RNCC prediction of high risk of death remained associated with the odds of 2-year mortality. LIMITATIONS This study was conducted in the context of a high-risk care management program, including an initial screening process and training, both of which affect the generalizability of the results. CONCLUSION When used in combination with a high-risk algorithm, the 2-year version of the SQ captured the majority of patients who died, demonstrating better than expected performance as a screening tool for a serious illness communication intervention in a heterogeneous primary care population.
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146
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Denholm R, Morris R, Payne R. Polypharmacy patterns in the last year of life in patients with dementia. Eur J Clin Pharmacol 2019; 75:1583-1591. [PMID: 31346649 DOI: 10.1007/s00228-019-02721-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/11/2019] [Indexed: 01/22/2023]
Abstract
PURPOSE To describe prescribing of medicines in primary care in the last year of life in patients with dementia. METHOD A retrospective cohort analysis in UK primary care using routinely collected data from the Clinical Practice Research Datalink. Number of medications and potentially inappropriate medication prescribed one year prior to, and including death, was ascertained. RESULTS Dementia patients (n = 6923) aged 86.6 ± 7.3 years (mean ± SD) were prescribed 4.8 ± 4.0 drugs 1 year prior to death, increasing to 5.6 ± 4.0 2 months prior, before falling to 4.9 ± 4.1 at death. One year prior to death, 50% of patients were prescribed a potentially inappropriate medication, falling to 41% at death. Cardiovascular medications were the most common, with decreases in drug count only occurring in the last month prior to death. Prescriptions for gastrointestinal and central nervous system medication increased throughout the year, particularly laxatives/analgaesics, antidepressants and hypnotic/antipsychotics. Women (vs. men) and patients with Alzheimer's (vs. vascular dementia) were prescribed 4.7% (95% CI 2.3%-7%) and 14.6% (11.7-17.3%) fewer medications, respectively. Prescribing decreased with age and increased with additional comorbidities. CONCLUSIONS Dementia patients are prescribed high levels of medication, many potentially inappropriate, during their last year of life, with reductions occurring relatively late. Improvements to medication optimisation guidelines are needed to inform decision-making around deprescribing of long-term medications in patients with limited life-expectancy.
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Affiliation(s)
- Rachel Denholm
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Richard Morris
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rupert Payne
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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147
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Ostgathe C, Wendt KN, Heckel M, Kurkowski S, Klein C, Krause SW, Fuchs FS, Bayer CM, Stiel S. Identifying the need for specialized palliative care in adult cancer patients - development and validation of a screening procedure based on proxy assessment by physicians and filter questions. BMC Cancer 2019; 19:646. [PMID: 31262285 PMCID: PMC6604384 DOI: 10.1186/s12885-019-5809-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 06/07/2019] [Indexed: 11/08/2022] Open
Abstract
Background One challenge in caring for cancer patients with incurable disease is the adequate identification of those in need for specialized palliative care (SPC). The study’s aim was to validate an easy to use phenomenological screening tool. Methods The German tool is based on the National Comprehensive Cancer Network (NCCN) Palliative Care guidelines and contains ten items in five domains that focus e.g. on diagnosis, functional status, complications, comorbidities, and palliative care relevant problems such as symptom management, distress, and support of family and team members. Sum score ranges from 0 to 14 (no need to great need). Assessment to identify SPC needs was done in university hospital wards between 1 and 08/2017 by health care professionals on admission of the patient if the disease was incurable and expected prognosis < 12 months. The Integrated Palliative Outcome Scale (IPOS, staff version), an outcome assessment instrument for palliative care that consists of ten items, served as external criterion; in sub samples inter-rater/test-retest were performed. Results Data from 208 patients with incurable disease and life expectancy < 12 months (54.8% female; average age 63.5 years, range 21–96) were assessed using the tool. The tool has good convergent validity; the correlation between the sum scores of IPOS and our tool showed a significant and substantial effect. The sum score was independent of the patient’s age, gender and primary diagnosis. Patients who already were in contact with SPC had significantly higher screening scores than patients without. With a cut point of ≥ 5, 80.8% of the screened patients were in need for SPC. Cronbach’s alpha was α = .600. Rater agreement (inter-rater, test-retest) varied between single items. Correlation coefficients showed significant substantial effects. Conclusions This is the first validation of a screening procedure in German language identifying SPC needs of adult patients with advanced cancer and the first using filter questions as a pre-screening. Proxy assessment of SPC needs by physicians in cancer care settings is feasible and the suggested tool presents a valid instrument to trigger a PC consultation. Trial registration The study was not registered.
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Affiliation(s)
- Christoph Ostgathe
- Comprehensive Cancer Center CCC Erlangen - EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany.,Department of Palliative Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - Kim N Wendt
- Comprehensive Cancer Center CCC Erlangen - EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany.,Department of Palliative Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - Maria Heckel
- Comprehensive Cancer Center CCC Erlangen - EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany. .,Department of Palliative Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany.
| | - Sandra Kurkowski
- Comprehensive Cancer Center CCC Erlangen - EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany.,Department of Palliative Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - Carsten Klein
- Comprehensive Cancer Center CCC Erlangen - EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany.,Department of Palliative Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - Stefan W Krause
- Comprehensive Cancer Center CCC Erlangen - EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany.,Department of Internal Medicine 5, Haematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - Florian S Fuchs
- Comprehensive Cancer Center CCC Erlangen - EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany.,Division of Respiratory Medicine, Department of Internal Medicine 1, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen , Erlangen, Germany
| | - Christian M Bayer
- Comprehensive Cancer Center CCC Erlangen - EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany.,Department of Gynecology and Obstetrics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, University Breast Center Franconia, Erlangen, Germany
| | - Stephanie Stiel
- Institute for General Practice, Hannover Medical School, Hannover, Germany
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148
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Abstract
An accurate prognosis about how long a terminally ill patient has left to live, when disclosed sensitively in open discussions, can facilitate patient-centred care and shared decision making. In addition, several guidelines, policies and funding streams rely, to some extent, on a clinician estimated prognosis. However, clinician predictions alone have been shown to be unreliable and over-optimistic. The factors underlying clinicians' prognostic decisions (particularly at the very end of life) are beginning to be elucidated. As an alternative to clinicians' subjective estimates, a number of prognostic algorithms and scores have been developed and validated, but only a few have consistently shown superiority to clinician predictions. Therefore, an element of uncertainty remains and this needs to be acknowledged when having conversations with patients and their families. Guidelines are available to advise clinicians about how to prepare for, participate in and record prognostic conversations.
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Affiliation(s)
- Christina Chu
- University College London, London, UK and specialty trainee in palliative medicine, Barts Health NHS Trust, London, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, University College London, London, UK
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149
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Lakin JR, Desai M, Engelman K, O'Connor N, Teuteberg WG, Coackley A, Kilpatrick LB, Gawande A, Fromme EK. Earlier identification of seriously ill patients: an implementation case series. BMJ Support Palliat Care 2019; 10:e31. [PMID: 31253734 DOI: 10.1136/bmjspcare-2019-001789] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/12/2019] [Accepted: 05/29/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe the strategies used by a collection of healthcare systems to apply different methods of identifying seriously ill patients for a targeted palliative care intervention to improve communication around goals and values. METHODS We present an implementation case series describing the experiences, challenges and best practices in applying patient selection strategies across multiple healthcare systems implementing the Serious Illness Care Program (SICP). RESULTS Five sites across the USA and England described their individual experiences implementing patient selection as part of the SICP. They employed a combination of clinician screens (such as the 'Surprise Question'), disease-specific criteria, existing registries or algorithms as a starting point. Notably, each describes adaptation and evolution of their patient selection methodology over time, with several sites moving towards using more advanced machine learning-based analytical approaches. CONCLUSIONS Involving clinical and programme staff to choose a simple initial method for patient identification is the ideal starting place for selecting patients for palliative care interventions. However, improving and refining methods over time is important and we need ongoing research into better patient selection methodologies that move beyond mortality prediction and instead focus on identifying seriously ill patients-those with poor quality of life, worsening functional status and medical care that is negatively impacting their families.
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Affiliation(s)
| | | | | | - Nina O'Connor
- Palliative and Hospice Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Winifred G Teuteberg
- Section of Palliative Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Alison Coackley
- Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, UK
| | - Laurel B Kilpatrick
- Division of Supportive and Palliative Care, Baylor Scott & White Health, Temple, Texas, USA
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150
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Molin Y, Gallay C, Gautier J, Lardy-Cleaud A, Mayet R, Grach MC, Guesdon G, Capodano G, Dubroeucq O, Bouleuc C, Bremaud N, Fogliarini A, Henry A, Caunes-Hilary N, Villet S, Villatte C, Frasie V, Triolaire V, Barbarot V, Commer JM, Hutin A, Chvetzoff G. PALLIA-10, a screening tool to identify patients needing palliative care referral in comprehensive cancer centers: A prospective multicentric study (PREPA-10). Cancer Med 2019; 8:2950-2961. [PMID: 31055887 PMCID: PMC6558580 DOI: 10.1002/cam4.2118] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/15/2019] [Accepted: 03/08/2019] [Indexed: 12/23/2022] Open
Abstract
Purpose The identification and referral of patients in need of palliative care should be improved. The French society for palliative support and care recommended to use the PALLIA‐10 questionnaire and its score greater than 3 to refer patients to palliative care. We explored the use of the PALLIA‐10 questionnaire and its related score in a population of advanced cancer patients. Methods This prospective multicentric study is to be conducted in authorized French comprehensive cancer centers on hospitalized patients on a given day. We aimed to use the PALLIA‐10 score to determine the proportion of palliative patients with a score >3. Main secondary endpoints were to determine the proportion of patients already managed by palliative care teams at the study date or referred to palliative care in six following months, the prevalence of patients with a score greater than 5, and the overall survival using the predefined thresholds of 3 and 5. Results In 2015, eighteen French cancer centers enrolled 840 patients, including 687 (82%) palliative patients. 479 (69.5%) patients had a score >3, 230 (33.5%) had a score >5, 216 (31.4%) patients were already followed‐up by a palliative care team, 152 patients were finally referred to PC in the six subsequent months. The PALLIA‐10 score appeared as a reliable predictive (adjusted ORRef≤3: 1.9 [1.17‐3.16] and 3.59 [2.18‐5.91]) and prognostic (adjusted HRRef≤3 = 1.58 [95%CI 1.20‐2.08] and 2.18 [95%CI 1.63‐2.92]) factor for patients scored 4‐5 and >5, respectively. Conclusion The PALLIA‐10 questionnaire is an easy‐to‐use tool to refer cancer inpatients to palliative care in current practice. However a score greater than 5 using the PALLIA‐10 questionnaire would be more appropriate for advanced cancer patients hospitalized in comprehensive cancer center.
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Affiliation(s)
| | | | - Julien Gautier
- Direction of Clinical Research and Innovation, Cancer center Léon Bérard, Lyon, France
| | - Audrey Lardy-Cleaud
- Direction of Clinical Research and Innovation, Cancer center Léon Bérard, Lyon, France
| | - Romaine Mayet
- Direction of Clinical Research and Innovation, Cancer center Léon Bérard, Lyon, France
| | | | | | | | | | | | | | | | - Aline Henry
- Cancer Institute of Lorraine - Alexis Vautrin, Nancy, France
| | | | | | | | | | | | - Véronique Barbarot
- West Cancer Institute, Saint Herblain, René Gauducheau Center, Nantes, France
| | | | - Agnès Hutin
- Eugène Marquis Cancer Center, Rennes, France
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