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Anagnostou D. Palliative care improves quality of life and reduces symptom burden in adults with life-limiting illness. Evid Based Nurs 2017; 20:47-48. [PMID: 28249959 DOI: 10.1136/eb-2016-102603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Despina Anagnostou
- Marie Curie Research Centre, School of Medicine, Cardiff University, Cardiff, UK
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152
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Estebsari F, Taghdisi MH, Mostafaei D, Rahimi Z. Elements of healthy death: a thematic analysis. Med J Islam Repub Iran 2017; 31:24. [PMID: 29445653 PMCID: PMC5804441 DOI: 10.18869/mjiri.31.24] [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: 07/17/2016] [Indexed: 11/23/2022] Open
Abstract
Background: Death is a natural and frightening phenomenon, which is inevitable. Previous studies on death, which presented a negative and tedious image of this process, are now being revised and directed towards acceptable death and good death. One of the proposed terms about death and dying is "healthy death", which encourages dealing with death positively and leading a lively and happy life until the last moment. This study aimed to explain the views of Iranians about the elements of healthy death. Methods: This qualitative study was conducted for 12 months in two general hospitals in Tehran (capital of Iran), using the thematic analysis method. After conducting 23 in-depth interviews with 21 participants, transcription of content, and data immersion and analysis, themes, as the smallest meaningful units were extracted, encoded and classified. Results: One main category of healthy death with 10 subthemes, including dying at the right time, dying without hassle, dying without cost, dying without dependency and control, peaceful death, not having difficulty at dying, not dying alone and dying at home, inspired death, preplanned death, and presence of a clergyman or a priest, were extracted as the elements of healthy death from the perspective of the participants in this study. Conclusion: The study findings well explained the elements of healthy death. Paying attention to the conditions and factors causing healthy death by professionals and providing and facilitating quality services for patients in the end stage of life make it possible for patients to experience a healthy death.
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Affiliation(s)
- Fatemeh Estebsari
- Department of Community Health Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Taghdisi
- Department of Health Education& Promotion, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | | | - Zahra Rahimi
- Department of Health Education, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
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153
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Naruse T, Yamamoto N, Sugimoto T, Fujisaki-Sakai M, Nagata S. The association between nurses' coordination with physicians and clients' place of death. Int J Palliat Nurs 2017; 23:136-142. [PMID: 28345476 DOI: 10.12968/ijpn.2017.23.3.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM Over 60% of Japanese people hope to die at home; hence, assisting clients in achieving this outcome is an important responsibility of home care providers. This study investigated the effects of nurses' relational coordination with physicians on clients' place of death in home visiting nursing (HVN) agencies. METHOD Secondary analysis of a public survey conducted in 2015 by local governments in Kurume city, Fukuoka prefecture, Western Japan. Manager nurses from 17 HVN agencies provided data about themselves and their relational coordination with community physicians and 85 deceased clients. RESULTS Among 85 deceased clients, 52 (61.2%) had died at home. Four regression models showed significant positive effects of HVN nurse managers' relational coordination on clients' home death (the odds ratios (95% CI) were 2.488 (1.442-4.293), 2.111 (1.014-4.396), 2.562 (1.409-4.658) and 2.275 (1.079-4.796) in models 1-4, respectively. CONCLUSION Measuring relational coordination among HVN nursing managers and physicians indicated readiness for home death among HVN clients in an agency or community.
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Affiliation(s)
- Takashi Naruse
- Lecturer, Department of Community Health Nursing, Graduate School of Medicine, University of Tokyo
| | - Natsuki Yamamoto
- Doctoral student, Department of Community Health Nursing, Graduate School of Medicine, University of Tokyo
| | - Takshi Sugimoto
- Department of Health Technology Assessment and Public Policy, Graduate School of Public Policy, University of Tokyo
| | - Mahiro Fujisaki-Sakai
- Research associate, Department of Community Health Nursing, Graduate School of Medicine, University of Tokyo
| | - Satoko Nagata
- Associate, Department of Community Health Nursing, Graduate School of Medicine, University of Tokyo
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154
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Fujita J, Fukui S, Ikezaki S, Otoguro C, Tsujimura M. Analysis of team types based on collaborative relationships among doctors, home-visiting nurses and care managers for effective support of patients in end-of-life home care. Geriatr Gerontol Int 2017; 17:1943-1950. [DOI: 10.1111/ggi.12998] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 11/12/2016] [Accepted: 12/07/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Junko Fujita
- Department of Community Health Nursing; Japanese Red Cross College of Nursing; Tokyo Japan
| | - Sakiko Fukui
- Department of Community Health Nursing; Japanese Red Cross College of Nursing; Tokyo Japan
| | - Sumie Ikezaki
- Health Administration in Nursing; Chiba University; Chiba Japan
| | - Chizuru Otoguro
- Department of Community Health Nursing; Japanese Red Cross College of Nursing; Tokyo Japan
| | - Mayuko Tsujimura
- Department of Visiting Nursing, Graduate School of Nursing; Chiba University; Chiba Japan
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155
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Ouchi K, Block SD, Schonberg MA, Jamieson ES, Aaronson EL, Pallin DJ, Tulsky JA, Schuur JD. Feasibility Testing of an Emergency Department Screening Tool To Identify Older Adults Appropriate for Palliative Care Consultation. J Palliat Med 2017; 20:69-73. [DOI: 10.1089/jpm.2016.0213] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
| | - Susan D. Block
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Emily S. Jamieson
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emily L. Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel J. Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeremiah D. Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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156
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Abstract
Palliative care consultation teams (PCCTs) provide input to other health-care providers working with patients who have life-limiting disease. This study examines whether the diction and phrasing of consultation recommendations in the electronic health record influence their implementation. We reviewed 288 verbatim PCCT recommendations that were made for 111 unique patients in a Veterans Affairs hospital and available in the electronic health record. Recommendations were coded for linguistic features, such as the presence of conditionals (e.g., "could") and tentative phrasing (e.g., "would suggest"). Each patient's subsequent treatment was followed in the medical record to determine whether PCCT recommendations were implemented. Only 57% of the consultation recommendations were eventually implemented. Recommendations that included a conditional word or phrase were significantly less likely to be implemented. In particular, recommendations that included the words "could" and "consider" were less likely to be implemented. PCCTs may enhance their effectiveness by attending to the subtle pragmatics of how they communicate with other health-care providers, particularly in electronic communication where nonverbal features of communication are unavailable.
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157
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Kain DA, Eisenhauer EA. Early integration of palliative care into standard oncology care: evidence and overcoming barriers to implementation. ACTA ACUST UNITED AC 2016; 23:374-377. [PMID: 28050132 DOI: 10.3747/co.23.3404] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In Canada, widespread discussion of medical aid in dying (http://www.parl.gc.ca/HousePublications/Publication.[...]
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Affiliation(s)
- D A Kain
- Department of Supportive Care, University Health Network, University of Toronto, Toronto, and
| | - E A Eisenhauer
- Department of Oncology, Queen's University, Kingston, ON
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158
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Comparison of end-of-life care for older people living at home and in residential homes: a mortality follow-back study among GPs in the Netherlands. Br J Gen Pract 2016; 65:e724-30. [PMID: 26500319 DOI: 10.3399/bjgp15x687349] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The proportion of older people is increasing, therefore their place of residence and place of care at the end of life are becoming increasingly important. AIM To compare aspects of end-of-life care among older people in residential homes and home settings in the Netherlands. DESIGN AND SETTING Nationwide representative mortality follow-back study among GPs in the Netherlands. METHOD The study included patients aged ≥65 years who died non-suddenly, whose longest place of residence in their last year of life was at home or in a residential home (n = 498). Differences were analysed using Pearson's χ(2) test, Mann-Whitney U tests, and multivariate logistic regression. RESULTS Controlling for the differences between the populations in home settings and residential homes, no differences were found in treatment goals, communication about end-of-life care, or use of specialised palliative care between the two settings. However, people living in a residential home were more likely to have received palliative care from a GP than people living at home (OR 2.84, 95% confidence interval [CI] = 1.41 to 5.07). In residential homes, people more often experienced no transfer between care settings (OR 2.76, 95% CI = 1.35 to 5.63) and no hospitalisations (OR 2.2, 95% CI = 1.04 to 4.67) in the last 3 months of life, and died in hospital less often (OR 0.78, 95% CI = 0.63 to 0.97) than those people living at home. CONCLUSION Despite similar treatment goals, care in residential homes seems more successful in avoiding transfers and hospitalisation at the end of life. Especially since older people are encouraged to stay at home longer, measures should be taken to ensure they are not at higher risk of transfers and hospitalisations in this setting.
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159
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Diop MS, Rudolph JL, Zimmerman KM, Richter MA, Skarf LM. Palliative Care Interventions for Patients with Heart Failure: A Systematic Review and Meta-Analysis. J Palliat Med 2016; 20:84-92. [PMID: 27912043 DOI: 10.1089/jpm.2016.0330] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To systematically characterize interventions and effectiveness of palliative care for advanced heart failure (HF) patients. BACKGROUND Patients with advanced heart failure experience a high burden of distressing symptoms and diminished quality of life. Palliative care expertise with symptom management and healthcare decision-making benefits HF patients. METHODS A systematic PubMed search was conducted from inception to June 2016 for studies of palliative care interventions for HF patients. Studies of humans with a HF diagnosis who underwent a palliative care intervention were included. Data were extracted on study design, participant characteristics, intervention components, and in three groups of outcomes: patient-centered outcomes, quality-of-death outcomes, and resource utilization. Study characteristics were examined to determine if meta-analysis was possible. RESULTS The fifteen identified studies varied in design (prospective, n = 10; retrospective, n = 5). Studies enrolled older patients, but greater variability was found for race, sex, and marital status. A majority of studies measuring patient-centered outcomes demonstrated improvements including quality of life and satisfaction. Quality-of-death outcomes were mixed with a majority of studies reporting clarification of care preferences, but less improvement in death at home and hospice enrollment. A meta-analysis in three studies found that home-based palliative care consults in HF patients lower the risk of rehospitalization by 42% (RR = 0.58; 95% Confidence Interval 0.44, 0.77). DISCUSSION Available evidence suggests that home and team-based palliative interventions for HF patients improve patient-centered outcomes, documentation of preferences, and utilization. Increased high quality studies will aid the determination of the most effective palliative care approaches for the HF population.
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Affiliation(s)
- Michelle S Diop
- 1 Primary Care and Population Medicine Program, Warren Alpert Medical School of Brown University , Providence, Rhode Island.,2 Center of Innovation for Long Term Services and Supports , Providence VAMC, Providence, Rhode Island
| | - James L Rudolph
- 2 Center of Innovation for Long Term Services and Supports , Providence VAMC, Providence, Rhode Island.,3 Department of Medicine, Warren Alpert Medical School of Brown University , Providence, Rhode Island.,4 Center for Gerontology, Brown University School of Public Health , Providence, Rhode Island
| | - Kristin M Zimmerman
- 5 Department of Pharmacotherapy and Outcomes, Virginia Commonwealth University , Richmond, Virginia
| | - Mary A Richter
- 6 Department of Obstetrics and Gynecology, Tulane University School of Medicine , New Orleans, Louisiana
| | - L Michal Skarf
- 7 Division of Geriatrics and Palliative Care, VA Boston Healthcare System , Boston, Massachusetts.,8 Harvard Medical School , Boston, Massachusetts
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161
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Duenk RG, Verhagen SC, Janssen MA, Dekhuijzen RP, Vissers KC, Engels Y, Heijdra Y. Consistency of medical record reporting of a set of indicators for proactive palliative care in patients with chronic obstructive pulmonary disease. Chron Respir Dis 2016; 14:63-71. [PMID: 27872166 DOI: 10.1177/1479972316661922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
To identify patients hospitalized for an acute exacerbation of chronic obstructive pulmonary disease (COPD) who have a poor prognosis and might benefit from proactive palliative care, a set of indicators had been developed from the literature. A patient is considered eligible for proactive palliative care when meeting ≥2 criteria of the proposed set of 11 indicators. In order to develop a doctor-friendly and patient-convenient tool, our primary objective was to examine whether these indicators are documented consistently in the medical records. Besides, percentage of patients with a poor prognosis and prognostic value were explored. We conducted a retrospective medical record review of 33 patients. Five indicators; non-invasive ventilation (NIV), comorbidity, body mass index (BMI), previous admissions for acute exacerbation COPD and age were always documented. Three indicators; hypoxaemia and/or hypercapnia, professional home care and actual forced expiratory volume1% (FEV1%) were documented in more than half of the records, whereas the clinical COPD questionnaire (CCQ), medical research council dyspnoea (MRC dyspnoea) and the surprise question were never registered. Besides, 78.8% of the patients met ≥2 criteria and there was a significant association between meeting ≥2 criteria and mortality within 1 year (one-sided Fisher's exact test, p = 0.04). The set of indicators for proactive palliative care in patients with COPD appeared to be user-friendly and feasible.
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Affiliation(s)
- Ria G Duenk
- 1 Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Stans C Verhagen
- 1 Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Mireille Ae Janssen
- 1 Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Richard Pnr Dekhuijzen
- 2 Department of Pulmonary Disease, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Kris Cp Vissers
- 1 Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Yvonne Engels
- 1 Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Yvonne Heijdra
- 2 Department of Pulmonary Disease, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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162
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Maltoni M, Scarpi E, Dall'Agata M, Schiavon S, Biasini C, Codecà C, Broglia CM, Sansoni E, Bortolussi R, Garetto F, Fioretto L, Cattaneo MT, Giacobino A, Luzzani M, Luchena G, Alquati S, Quadrini S, Zagonel V, Cavanna L, Ferrari D, Pedrazzoli P, Frassineti GL, Galiano A, Casadei Gardini A, Monti M, Nanni O. Systematic versus on-demand early palliative care: A randomised clinical trial assessing quality of care and treatment aggressiveness near the end of life. Eur J Cancer 2016; 69:110-118. [PMID: 27821313 DOI: 10.1016/j.ejca.2016.10.004] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/05/2016] [Indexed: 01/19/2023]
Abstract
AIM Early palliative care (EPC) in oncology has shown sparse evidence of a positive impact on patient outcomes, quality of care outcomes and costs. PATIENTS AND METHODS Data for this secondary analysis were taken from a trial of 207 outpatients with metastatic pancreatic cancer randomly assigned to receive standard cancer care plus on-demand EPC (standard arm) or standard cancer care plus systematic EPC (interventional arm). After 20 months' follow-up, 149 (80%) had died. Outcome measures were frequency, type and timing of chemotherapy administration, use of resources, place of death and overall survival. RESULTS Some indices of end-of-life (EoL) aggressiveness had a favourable impact from systematic EPC. Interventional arm patients showed higher use of hospice services: a significantly longer median and mean period of hospice care (P = 0.025 for both indexes) and a significantly higher median and mean number of hospice admissions (both P < 0.010). In the experimental arm, chemotherapy was performed in the last 30 days of life in a significantly inferior rate with respect to control arm: 18.7% versus 27.8% (adjusted P = 0.036). Other non-significant differences were seen in favour of experimental arm. CONCLUSIONS Systematic EPC showed a significant impact on some indicators of EoL treatment aggressiveness. These data, reinforced by multiple non-significant differences in most of the other items, suggest that quality of care is improved by this approach. This study is registered on ClinicalTrials.gov (NCT01996540).
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Affiliation(s)
- Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Emanuela Scarpi
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy.
| | - Monia Dall'Agata
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Stefania Schiavon
- Pain Therapy and Palliative Care Unit, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Claudia Biasini
- Medical Oncology Unit, Oncology-Hematology Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Carla Codecà
- Medical Oncology Unit, San Paolo Hospital, Milan, Italy
| | | | - Elisabetta Sansoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Roberto Bortolussi
- Palliative Care and Pain Therapy Unit, Aviano National Cancer Institute, Aviano, Italy
| | | | - Luisa Fioretto
- Medical Oncology Unit, Oncology Department, S. Maria Annunziata Hospital, Florence, Italy
| | | | | | - Massimo Luzzani
- Palliative Care, Department of Geriatric, Orthogeriatric and Rehabilitation Frailty Area, E.O. Galliera Hospitals, Genoa, Italy
| | | | - Sara Alquati
- Palliative Care Unit, Arcispedale S. Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Silvia Quadrini
- Oncology Unit, SS Trinità Hospital Sora, ASL Frosinone, Italy
| | - Vittorina Zagonel
- Department of Clinical and Experimental Oncology, Medical Oncology Unit 1, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Luigi Cavanna
- Medical Oncology Unit, Oncology-Hematology Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Daris Ferrari
- Medical Oncology Unit, San Paolo Hospital, Milan, Italy
| | - Paolo Pedrazzoli
- Oncology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giovanni Luca Frassineti
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Antonella Galiano
- Department of Clinical and Experimental Oncology, Medical Oncology Unit 1, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Andrea Casadei Gardini
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Manlio Monti
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Oriana Nanni
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
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163
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Yang GM, Neo SHS, Lim SZZ, Krishna LKR. Effectiveness of Hospital Palliative Care Teams for Cancer Inpatients: A Systematic Review. J Palliat Med 2016; 19:1156-1165. [DOI: 10.1089/jpm.2016.0052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Grace Meijuan Yang
- Department of Palliative Medicine, National Cancer Centre Singapore, Singapore, Singapore
| | - Shirlyn Hui-Shan Neo
- Department of Palliative Medicine, National Cancer Centre Singapore, Singapore, Singapore
| | - Shawn Zhi Zheng Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Bone AE, Morgan M, Maddocks M, Sleeman KE, Wright J, Taherzadeh S, Ellis-Smith C, Higginson IJ, Evans CJ. Developing a model of short-term integrated palliative and supportive care for frail older people in community settings: perspectives of older people, carers and other key stakeholders. Age Ageing 2016; 45:863-873. [PMID: 27586857 PMCID: PMC5105822 DOI: 10.1093/ageing/afw124] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/18/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND understanding how best to provide palliative care for frail older people with non-malignant conditions is an international priority. We aimed to develop a community-based episodic model of short-term integrated palliative and supportive care (SIPS) based on the views of service users and other key stakeholders in the United Kingdom. METHOD transparent expert consultations with health professionals, voluntary sector and carer representatives including a consensus survey; and focus groups with older people and carers were used to generate recommendations for the SIPS model. Discussions focused on three key components of the model: potential benefit of SIPS, timing of delivery and processes of integrated working between specialist palliative care and generalist practitioners. Content and descriptive analysis was employed and findings were integrated across the data sources. FINDINGS we conducted two expert consultations (n = 63), a consensus survey (n = 42) and three focus groups (n = 17). Potential benefits of SIPS included holistic assessment, opportunity for end of life discussion, symptom management and carer reassurance. Older people and carers advocated early access to SIPS, while other stakeholders proposed delivery based on complex symptom burden. A priority for integrated working was the assignment of a key worker to co-ordinate care, but the assignment criteria remain uncertain. INTERPRETATION key stakeholders agree that a model of SIPS for frail older people with non-malignant conditions has potential benefits within community settings, but differ in opinion on the optimal timing and indications for this service. Our findings highlight the importance of consulting all key stakeholders in model development prior to feasibility evaluation.
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Affiliation(s)
- Anna E. Bone
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | - Myfanwy Morgan
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - Matthew Maddocks
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | - Katherine E. Sleeman
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | - Juliet Wright
- Department of Geriatric Medicine, Brighton and Sussex Medical School, Brighton, UK
| | | | - Clare Ellis-Smith
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | - Irene J. Higginson
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | - Catherine J. Evans
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
- Sussex Community NHS Trust, Brighton and Hove, UK
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165
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Cea ME, Reid MC, Inturrisi C, Witkin LR, Prigerson HG, Bao Y. Pain Assessment, Management, and Control Among Patients 65 Years or Older Receiving Hospice Care in the U.S. J Pain Symptom Manage 2016; 52:663-672. [PMID: 27693900 PMCID: PMC5473027 DOI: 10.1016/j.jpainsymman.2016.05.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 05/09/2016] [Accepted: 05/24/2016] [Indexed: 11/19/2022]
Abstract
CONTEXT Knowledge is limited regarding pain assessment and management practices, as well as pain-related outcomes in hospice care. OBJECTIVES To generate national estimates of pain assessment and management practices and outcomes of pain control among patients 65 years or older receiving hospice care in the U.S. and identify hospice discharge and agency characteristics predicting study outcomes. METHODS The 2007 National Home Health and Hospice Care Survey was analyzed. Multivariate logistic regressions were estimated to identify discharge and agency characteristics predicting guideline-concordant pain assessment and management practices and pain control outcomes. RESULTS A high percentage of discharges had pain assessment at admission (97%) and before discharge (93%); use of valid pain rating scales was relatively low (69% and 54% for first and last assessments, respectively). Almost 95% of patients received pain medication, but only 42% received nonpharmacologic therapies. About 70% of patients assessed with a valid pain scale saw improvement in the level of pain or remained free of pain from admission to discharge. Non-Hispanic blacks were less likely to have pain assessments, and Hispanics were less likely to receive opioid analgesics or to have pain-free status at discharge, compared with non-Hispanic whites. Patients receiving care from for-profit (vs. nonprofit) agencies were more likely to receive pain assessment with a valid scale before discharge but less likely to experience pain control or improvement. CONCLUSION Greater use of valid pain assessment scales and nonpharmacologic therapies constitutes areas for improvement in hospice care. Targeted interventions are needed to address disparities in pain care by patient race and/or ethnicity and agency ownership status.
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Affiliation(s)
- Meagan E Cea
- Department of Radiology, Weill Cornell Medical College, New York, New York, USA
| | - M Cary Reid
- Division of Geriatrics and Palliative Care, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Charles Inturrisi
- Department of Pharmacology, Weill Cornell Medical College, New York, New York, USA
| | - Lisa R Witkin
- Weill Cornell Pain Medicine, Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Holly G Prigerson
- Division of Geriatrics and Palliative Care, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Yuhua Bao
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA; Department of Psychiatry, Weill Cornell Medical College, New York, New York, USA.
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Halpern MT, Urato MP, Kent EE. The health care experience of patients with cancer during the last year of life: Analysis of the SEER-CAHPS data set. Cancer 2016; 123:336-344. [PMID: 27654842 DOI: 10.1002/cncr.30319] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 07/02/2016] [Accepted: 08/05/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Providing high-quality medical care for individuals with cancer during their last year of life involves a range of challenges. An important component of high-quality care during this critical period is ensuring optimal patient satisfaction. The objective of the current study was to assess factors influencing health care ratings among individuals with cancer within 1 year before death. METHODS The current study used the Surveillance, Epidemiology, and End Results (SEER)-Consumer Assessment of Healthcare Providers and Systems (CAHPS) data set, a new data resource linking patient-reported information from the CAHPS Medicare Survey with clinical information from the National Cancer Institute's SEER program. The study included 5102 Medicare beneficiaries diagnosed with cancer who completed CAHPS between 1998 and 2011 within 1 year before their death. Multivariable logistic regression analyses examined associations between patient demographic and insurance characteristics with 9 measures of health care experience. RESULTS Patients with higher general or mental health status were significantly more likely to indicate excellent experience with nearly all measures examined. Sex, race/ethnicity, and education also were found to be significant predictors for certain ratings. Greater time before death predicted an increased likelihood of higher ratings for health plan and specialist physician. Clinical characteristics were found to have few significant associations with experience of care. Individuals in fee-for-service Medicare plans (vs Medicare Advantage) had a greater likelihood of excellent experience with health plans, getting care quickly, and getting needed care. CONCLUSIONS Among patients with cancer within 1 year before death, experience with health plans, physicians, and medical care were found to be associated with sociodemographic, insurance, and clinical characteristics. These findings provide guidance for the development of programs to improve the experience of care among individuals with cancer. Cancer 2017;123:336-344. © 2016 American Cancer Society.
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Affiliation(s)
- Michael T Halpern
- RTI International, Research Triangle Park, North Carolina.,Department of Health Services Administration and Policy, Temple University College of Public Health, Philadelphia, Pennsylvania
| | | | - Erin E Kent
- Outcomes Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
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Daveson BA, Smith M, Yi D, McCrone P, Grande G, Todd C, Gysels M, Costantini M, Murtagh FE, Higginson IJ, Evans CJ. The effectiveness and cost-effectiveness of inpatient specialist palliative care in acute hospitals for adults with advanced illness and their caregivers. Hippokratia 2016. [DOI: 10.1002/14651858.cd011619.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Barbara A Daveson
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
| | - Melinda Smith
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
| | - Deokhee Yi
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
| | - Paul McCrone
- King's College London; Institute of Psychiatry; Box P024 De Crespigny Park London UK SE5 8AF
| | - Gunn Grande
- University of Manchester; School of Nursing, Midwifery and Social Work; Jean McFarlane Building Oxford Road Manchester Greater Manchester UK M13 9PL
| | - Chris Todd
- University of Manchester; School of Nursing, Midwifery and Social Work; Jean McFarlane Building Oxford Road Manchester Greater Manchester UK M13 9PL
| | - Marjolein Gysels
- University of Amsterdam; Amsterdam Institute of Social Science Research; Amsterdam Netherlands
| | - Massimo Costantini
- IRCCS Arcispedale S. Maria Nuova; Palliative Care Unit; Reggio Emilia Italy
| | - F E Murtagh
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
| | - Irene J Higginson
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
| | - Catherine J Evans
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
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168
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Experiences of security and continuity of care: Patients' and families' narratives about the work of specialized palliative home care teams. Palliat Support Care 2016; 15:181-189. [PMID: 27443410 DOI: 10.1017/s1478951516000547] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Those who are seriously ill and facing death are often living with physical, emotional, social, and spiritual suffering. Teamwork is considered to be necessary to holistically meet the diverse needs of patients in palliative care. Reviews of studies regarding palliative care team outcomes have concluded that teams provide benefits, especially regarding pain and symptom management. Much of the research concerning palliative care teams has been performed from the perspective of the service providers and has less often focused on patients' and families' experiences of care. OBJECTIVE Our aim was to investigate how the team's work is manifested in care episodes narrated by patients and families in specialized palliative home care (SPHC). METHOD A total of 13 interviews were conducted with patients and families receiving specialized home care. Six patients and seven family members were recruited through SPHC team leaders. Interviews were transcribed verbatim and the transcripts qualitatively analyzed into themes. RESULTS Two themes were constructed through thematic analysis: (1) security ("They are always available," "I get the help I need quickly"); and (2) continuity of care ("They know me/us, our whole situation and they really care"). Of the 74 care episodes, 50 were descriptions of regularly scheduled visits, while 24 related to acute care visits and/or interventions. SIGNIFICANCE OF RESULTS Patients' and family members' descriptions of the work of SPHC teams are conceptualized through experiences of security and continuity of care. Experiences of security are fostered through the 24/7 availability of the team, sensitivity and flexibility in meeting patients' and families' needs, and practical adjustments to enable care at home. Experiences of continuity of care are fostered through the team's collective approach, where the individual team member knows the patients and family members, including their whole situation, and cares about the little things in life as well as caring for the family unit.
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Yoshimoto T, Tomiyasu S, Saeki T, Tamaki T, Hashizume T, Murakami M, Matoba M. How Do Hospital Palliative Care Teams Use the WHO Guidelines to Manage Unrelieved Cancer Pain? A 1-Year, Multicenter Audit in Japan. Am J Hosp Palliat Care 2016; 34:92-99. [DOI: 10.1177/1049909115608810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
It has been reported that pain relief for patients with cancer is suboptimal in Japan. This has been mainly attributed to inadequate dissemination of the World Health Organization (WHO) guidelines for cancer pain management. To better understand this problem, we reviewed how 6 hospital palliative care teams (HPCTs) used the WHO guidelines for unrelieved pain in a 1-year audit that included 534 patients. The HPCT interventions were classified according to the contents of the WHO guidelines. In our study, HPCT interventions involved opioid prescriptions in >80% of referred patients, and “For the Individual” and “Attention to Detail” were the 2 most important principles. Our study indicates which parts of the WHO guidelines should be most heavily emphasized, when disseminating them in Japan.
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Affiliation(s)
| | - Shiro Tomiyasu
- Department of Anesthesia and Palliative Care, Nishida Hospital, Saga, Japan
| | - Toshinari Saeki
- Department of Palliative Care Medicine, Municipal Miyoshi Central Hospital, Hiroshima, Japan
| | - Tomohiro Tamaki
- Department of Palliative Care, Cancer Center, Hokkaido University Hospital, Hokkaido, Japan
| | | | - Masahiko Murakami
- Department of Palliative Care Medicine, Iwate Prefectural Ofunato Hospital, Iwate, Japan
| | - Motohiro Matoba
- Department of Palliative Care Medicine, Japanese Red Cross Medical Center, Tokyo, Japan
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Abstract
BACKGROUND AND AIM Americans rely on the Internet for health information, and people are likely to turn to online resources to learn about palliative care as well. The purpose of this study was to analyze online palliative care information pages to evaluate the breadth of their content. We also compared how frequently basic facts about palliative care appeared on the Web pages to expert rankings of the importance of those facts to understanding palliative care. DESIGN Twenty-six pages were identified. Two researchers independently coded each page for content. Palliative care professionals (n = 20) rated the importance of content domains for comparison with content frequency in the Web pages. RESULTS We identified 22 recurring broad concepts about palliative care. Each information page included, on average, 9.2 of these broad concepts (standard deviation [SD] = 3.36, range = 5-15). Similarly, each broad concept was present in an average of 45% of the Web pages (SD = 30.4%, range = 8%-96%). Significant discrepancies emerged between expert ratings of the importance of the broad concepts and the frequency of their appearance in the Web pages ( rτ = .25, P > .05). CONCLUSION AND IMPLICATIONS This study demonstrates that palliative care information pages available online vary considerably in their content coverage. Furthermore, information that palliative care professionals rate as important for consumers to know is not always included in Web pages. We developed guidelines for information pages for the purpose of educating consumers in a consistent way about palliative care.
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Affiliation(s)
- Elissa Kozlov
- 1 Department of Psychology, Washington University in St Louis, St Louis, MO, USA
| | - Brian D Carpenter
- 1 Department of Psychology, Washington University in St Louis, St Louis, MO, USA
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171
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Şenel G, Uysal N, Oguz G, Kaya M, Kadioullari N, Koçak N, Karaca S. Delirium Frequency and Risk Factors Among Patients With Cancer in Palliative Care Unit. Am J Hosp Palliat Care 2016; 34:282-286. [PMID: 26722008 DOI: 10.1177/1049909115624703] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introductıon: Delirium is a complex but common disorder in palliative care with a prevalence between 13% and 88% but a particular frequency at the end of life yet often remains insufficiently diagnosed and managed. The aim of our study is to determine the frequency of delirium and identify factors associated with delirium at palliative care unit. METHODS Two hundred thirteen consecutive inpatients from October 1, 2012, to March 31, 2013, were studied prospectively. Age, gender, Palliative Performance Scale (PPS), Palliative Prognostic Index (PPI), length of stay in hospital, and delirium etiology and subtype were recorded. Delirium was diagnosed with using Delirium Rating Scale (DRS) and Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision ( DSM-IV TR) criteria. RESULTS The incidence of delirium among the patients with cancer was 49.8%. Mean age was 60.3 ± 14.8 (female 41%, male 59%, PPS 39.8%, PPI 5.9 ± 3.0, length of stay in hospital 8.6 ± 6.9 days). Univariate logistic regression analysis indicated that use of opioids, anticonvulsants, benzodiazepines, steroids, polypharmacy, infection, malnutrition, immobilization, sleep disturbance, constipation, hyperbilirubinemia, liver/renal failure, pulmonary failure/hypoxia, electrolyte imbalance, brain cancer/metastases, decreased PPS, and increased PPI were risk factors. Subtypes of delirium included hypoactive 49%, mixed 41%, and hyperactive 10%. CONCLUSION The communicative impediments associated with delirium generate distress for the patient, their family, and health care practitioners who might have to contend with agitation and difficulty in assessing pain and other symptoms. To manage delirium in patients with cancer, clinicians must be able to diagnose it accurately and undertake appropriate assessment of underlying causes.
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Affiliation(s)
- Gülcin Şenel
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Neşe Uysal
- 2 Nursing Department, Faculty of Health Science, Gazi University Ankara, Turkey
| | - Gonca Oguz
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Mensure Kaya
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Nihal Kadioullari
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Nesteren Koçak
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Serife Karaca
- 1 Palliative Care Clinic, Ankara Oncology Education and Research Hospital, Ankara, Turkey
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de Graaf E, Zweers D, Valkenburg AC, Uyttewaal A, Teunissen SC. Hospice assist at home: does the integration of hospice care in primary healthcare support patients to die in their preferred location - A retrospective cross-sectional evaluation study. Palliat Med 2016; 30:580-6. [PMID: 26814216 DOI: 10.1177/0269216315626353] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A majority of patients prefer to die at home. Specialist palliative care aims to improve quality of life. Hospice assist at home is a Dutch model of general/specialised palliative care within primary care, collaboratively built by general practitioners and a hospice. AIM The aims of this study are to explore whether hospice assist at home service enables patients at hometo express end-of-life preferences and die in their preferred location. In addition, this study provides insight into symptomburden, stability and early referral. DESIGN A retrospective cross-sectional evaluation study was performed (December 2014-March 2015), using hospice assist at home patient records and documentation. Primary outcome includes congruence between preferred and actual place of death. Secondary outcomes include symptom burden, (in)stability and early identification. SETTING/PARTICIPANTS Between June 2012 and December 2014, 130 hospice assist at home patients, living at home with a life expectancy <1 year, were enrolled. Hospice assist at home, a collaboration between general practitioners, district nurses, trained volunteers and a hospice team, facilitates (1) general practitioner-initiated consultation by Nurse Consultant Hospice, (2) fortnightly interdisciplinary consultations and (3) 24/7 hospice backup for patients, caregivers and professionals. RESULTS A total of 130 patients (62 (48%) men; mean age, 72 years) were enrolled, of whom 107/130 (82%) died and 5 dropped out. Preferred place of death was known for 101/107 (94%) patients of whom 91% patients died at their preferred place of death. CONCLUSION Hospice assist at home service supports patients to die in their preferred place of death. Shared responsibility of proactive care in primary care collaboration enabled patients to express preferences. Hospice care should focus on local teamwork, to contribute to shared responsibilities in providing optimal palliative care.
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Affiliation(s)
- Everlien de Graaf
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands Academic Hospice Demeter, De Bilt, The Netherlands
| | - Daniëlle Zweers
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anna Ch Valkenburg
- Academic Hospice Demeter, De Bilt, The Netherlands Community Health Center, De Bilt, The Netherlands
| | | | - Saskia Ccm Teunissen
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands Academic Hospice Demeter, De Bilt, The Netherlands
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Bainbridge D, Seow H, Sussman J. Common Components of Efficacious In-Home End-of-Life Care Programs: A Review of Systematic Reviews. J Am Geriatr Soc 2016; 64:632-9. [DOI: 10.1111/jgs.14025] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Daryl Bainbridge
- Department of Oncology; McMaster University; Hamilton Ontario Canada
| | - Hsien Seow
- Department of Oncology; McMaster University; Hamilton Ontario Canada
- Escarpment Cancer Research Institute; Hamilton Ontario Canada
| | - Jonathan Sussman
- Department of Oncology; McMaster University; Hamilton Ontario Canada
- Escarpment Cancer Research Institute; Hamilton Ontario Canada
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Karasouli E, Munday D, Bailey C, Staniszewska S, Hewison A, Griffiths F. Qualitative critical incident study of patients' experiences leading to emergency hospital admission with advanced respiratory illness. BMJ Open 2016; 6:e009030. [PMID: 26916687 PMCID: PMC4769410 DOI: 10.1136/bmjopen-2015-009030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES The high volume of emergency admissions to hospital is a challenge for health systems internationally. Patients with lung cancer and chronic obstructive pulmonary disease (COPD) are frequently admitted to hospital as emergency cases. While the frequency of emergency admission has been investigated, few studies report patient experiences, particularly in relation to the decision-making process prior to emergency admission. We sought to explore patient and carer experiences and those of their healthcare professionals in the period leading up to emergency admission to hospital. SETTING 3 UK hospitals located in different urban and rural settings. DESIGN Qualitative critical incident study. PARTICIPANTS 24 patients with advanced lung cancer and 15 with advanced COPD admitted to hospital as emergencies, 20 of their carers and 50 of the health professionals involved in the patients' care. RESULTS The analysis of patient, carer and professionals' interviews revealed a detailed picture of the complex processes involved leading to emergency admission to hospital. 3 phases were apparent in this period: self-management of deteriorating symptoms, negotiated decision-making and letting go. These were dynamic processes, characterised by an often rapidly changing clinical condition, uncertainty and anxiety. Patients considered their options drawing on experience, current and earlier advice. Patients tried to avoid admission, reluctantly accepting it, albeit often with a sense of relief, as anxiety increased with worsening symptoms. CONCLUSIONS Patients with advanced respiratory illness, and their carers, try to avoid emergency admission, and use logical and complex decision-making before reluctantly accepting it. Clinicians and policy-makers need to understand this complex process when considering how to reduce emergency hospital admissions rather than focusing on identifying and labelling admissions as 'inappropriate'.
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Affiliation(s)
- Eleni Karasouli
- Warwick Manufacturing Group (WMG), University of Warwick, Coventry, UK
| | - Daniel Munday
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Cara Bailey
- School of Nursing, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Sophie Staniszewska
- Division of Health Sciences, Royal College of Nursing Research Institute, Warwick Medical School, University of Warwick, Coventry, UK
| | - Alistair Hewison
- School of Nursing, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Seow H, Barbera L, Pataky R, Lawson B, O'Leary E, Fassbender K, McGrail K, Burge F, Brouwers M, Sutradhar R. Does Increasing Home Care Nursing Reduce Emergency Department Visits at the End of Life? A Population-Based Cohort Study of Cancer Decedents. J Pain Symptom Manage 2016; 51:204-12. [PMID: 26514717 DOI: 10.1016/j.jpainsymman.2015.10.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 10/15/2015] [Accepted: 10/21/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT Despite being commonplace in health care systems, little research has described home care nursing's effectiveness to reduce acute care use at the end of life. OBJECTIVES To examine the temporal association between home care nursing rate on emergency department (ED) visit rate in the subsequent week during the last six months of life. METHODS We conducted a retrospective cohort study of end-of-life cancer decedents in Ontario, Canada, from 2004 to 2009 by linking administrative databases. We examined the association between home care nursing rate of one week with the ED rate in the subsequent week closer to death, controlling for covariates and repeated measures among decedents. Nursing was dichotomized into standard and end-of-life care intent. RESULTS Our cohort included 54,576 decedents who used home care nursing services in the last six months before death, where 85% had an ED visit and 68% received end-of-life home care nursing. Patients receiving end-of-life nursing at any week had a significantly reduced ED rate in the subsequent week of 31% (relative rate [RR] 0.69; 95% confidence interval [CI] 0.68, 0.71) compared with standard nursing. In the last month of life, receiving end-of-life nursing and standard nursing rate of more than five hours/week was associated with a decreased ED rate of 41% (RR 0.59, 95% CI 0.58, 0.61) and 32% (RR 0.68, 95% CI 0.66, 0.70), respectively, compared with standard nursing of one hour/week. CONCLUSION Our study showed a temporal association between receiving end-of-life nursing in a given week during the last six months of life, and of more standard nursing in the last month of life, with a reduced ED rate in the subsequent week.
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Affiliation(s)
- Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada.
| | - Lisa Barbera
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Odette Cancer Centre, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Reka Pataky
- British Columbia Cancer Research Centre, Vancouver, British Columbia, Canada
| | - Beverley Lawson
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Erin O'Leary
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Konrad Fassbender
- Department of Palliative Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kim McGrail
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fred Burge
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Melissa Brouwers
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Rinku Sutradhar
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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177
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Seow H, Sutradhar R, McGrail K, Fassbender K, Pataky R, Lawson B, Sussman J, Burge F, Barbera L. End-of-Life Cancer Care: Temporal Association between Homecare Nursing and Hospitalizations. J Palliat Med 2015; 19:263-70. [PMID: 26673031 DOI: 10.1089/jpm.2015.0229] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Most cancer patients want to die at home, but scaleable models to achieve this are not well researched. Our objective was to investigate the temporal association of homecare nursing, especially by generalist nurses, with reduced end-of-life hospitalizations. METHODS We conducted a retrospective Canadian cohort study of end-of-life cancer decedents during 2004-2009 in Ontario (ON), Nova Scotia (NS), and British Columbia (BC), which have homecare systems that use generalist nurses to provide end-of-life care. Each province linked administrative databases to examine the association during the last six months of life between the homecare nursing rate and the hospitalization rate in the subsequent week, using standardized definitions and controlling for other covariates. We dichotomized nursing into standard and end-of-life care intent. RESULTS Our cohort included 83,827 cancer decedents. Approximately 55% of decedents were older than 70 and the most common cancer was lung. Nearly 85% of the cohort had at least one hospital admission. Receiving end-of-life compared to standard homecare nursing significantly reduced a patient's hospitalization rate by 34%, 33%, and 17% in ON, BC, and NS. In the last month of life patients having a standard nursing rate of greater than five hours compared to one hour per week had a significantly lower hospitalization rate (relative reduction of 15%-23%) across the three provinces. CONCLUSIONS Our study showed a protective effect of nursing with an end-of-life intent on hospitalization across the last six months of life and of standard nursing in the last month. This finding's generalizability is strengthened, since the trends were similar across three different homecare systems.
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Affiliation(s)
- Hsien Seow
- 1 Department of Oncology, McMaster University , Hamilton, Ontario, Canada
| | - Rinku Sutradhar
- 2 Institute for Clinical Evaluative Sciences , Toronto, Ontario, Canada .,3 Dalla Lana School of Public Health, University of Toronto , Toronto, Ontario, Canada
| | - Kim McGrail
- 4 School of Population and Public Health, University of British Columbia , Vancouver, British Columbia, Canada
| | - Konrad Fassbender
- 5 Department of Oncology, University of Alberta , Edmonton, Alberta, Canada
| | - Reka Pataky
- 6 Canadian Centre for Applied Research in Cancer Control , Vancouver, British Columbia, Canada .,7 British Columbia Cancer Research Centre , Vancouver, British Columbia, Canada
| | - Beverley Lawson
- 8 Department of Family Medicine, Dalhousie University , Halifax, Nova Scotia, Canada
| | - Jonathan Sussman
- 1 Department of Oncology, McMaster University , Hamilton, Ontario, Canada
| | - Fred Burge
- 8 Department of Family Medicine, Dalhousie University , Halifax, Nova Scotia, Canada
| | - Lisa Barbera
- 2 Institute for Clinical Evaluative Sciences , Toronto, Ontario, Canada .,9 Department of Radiation Oncology, University of Toronto , Toronto, Ontario, Canada
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Bainbridge D, Seow H, Sussman J, Pond G. Factors associated with acute care use among nursing home residents dying of cancer: a population-based study. Int J Palliat Nurs 2015. [PMID: 26203955 DOI: 10.12968/ijpn.2015.21.7.349] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Little is known about residents of long-term care (LTC) facilities who die of cancer. The authors examined factors among this cohort prognostic of greater acute care use to identify areas for improving support in LTC. METHODS The authors used administrative data representing all cancer decedents in Ontario, Canada, who had been living in LTC. Binary logistic regression was used to examine the contribution of covariates to having an emergency department (ED) visit in the last 6 months of life or to death in hospital. RESULTS Among the 1196 LTC residents in the study cohort, 61% had visited an ED in the last 6 months of life and 20% had died in hospital. Cancer type, income, gender, time in LTC and rural location were not strong predictors of the acute care outcomes. However, certain comorbidities, being younger and region of residence significantly increased the odds of an ED visit and/or hospital death (all P<0.05). CONCLUSIONS Determining the characteristics of LTC patients more likely to access acute care services can help to inform interventions that avoid costly and potentially adverse transfers to hospital. The study of cancer patients in LTC represents a starting point for clarifying the potential of specialised palliative care nursing and other support that is often lacking in these facilities.
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Affiliation(s)
- Daryl Bainbridge
- Senior Research Coordinator, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Hsien Seow
- Associate Professor, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Jonathan Sussman
- Associate Professor, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Gregory Pond
- Associate Professor; all at Department of Oncology, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
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The positioning of palliative care in acute care: A multiperspective qualitative study in the context of metastatic melanoma. Palliat Support Care 2015; 14:259-68. [PMID: 26456174 DOI: 10.1017/s1478951515000917] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The positioning and meaning of palliative care within the healthcare system lacks clarity which adds a level of complexity to the process of transition to palliative care. This study explores the transition to the palliative care process in the acute care context of metastatic melanoma. METHOD A theoretical framework drawing on interpretive and critical traditions informs this research. The pragmatism of symbolic interactionism and the critical theory of Habermas brought a broad orientation to the research. Integration of the theoretical framework and grounded-theory methods facilitated data generation and analysis of 29 interviews with patients, family carers, and healthcare professionals. RESULTS The key analytical findings depict a scope of palliative care that was uncertain for users of the system and for those working within the system. Becoming "palliative" is not a defined event; nor is there unanimity around referral to a palliative care service. As such, ambiguity and tension contribute to the difficulties involved in negotiating the transition to palliative care. SIGNIFICANCE OF RESULTS Our findings point to uncertainty around the scopes of practice in the transition to palliative care. The challenge in the transition process lies in achieving greater coherency of care within an increasingly specialized healthcare system. The findings may not only inform those within a metastatic melanoma context but may contribute more broadly to palliative practices within the acute care setting.
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Ledford CJW, Canzona MR, Cafferty LA, Kalish VB. Negotiating the equivocality of palliative care: a grounded theory of team communicative processes in inpatient medicine. HEALTH COMMUNICATION 2015; 31:536-543. [PMID: 26431077 DOI: 10.1080/10410236.2014.974134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
In the majority of U.S. hospitals, inpatient medicine teams make palliative care decisions in the absence of a formalized palliative system. Using a grounded theory approach, interviews with inpatient team members were systematically analyzed to uncover how participants conceptualize palliative care and how they regard the communicative structures that underlie its delivery. During analysis, Weick's model of organizing emerged as a framework that fit the data. The 39 participant inpatient team members discussed palliative care as primarily a communicative process. Themes describing the meaning of palliative care emerged around the concepts of receiver of care, timeline of care, and location of care. The emerging model included four stages in the communicative processes of inpatient palliative care: (a) interpret the need, (b) initiate the conversation, (c) integrate the processes, and (d) identify what works. In contrast to stable, focused palliative care teams or hospice care teams, which have prescribed patient populations and processes, the inpatient medicine team faces the equivocality of providing palliative care within a broader practice. This research offers a four-phase model to show how these inpatient teams communicate within this context. Implications for the provision of palliative care are discussed.
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Affiliation(s)
- Christy J W Ledford
- a Department of Family Medicine , Uniformed Services University of the Health Sciences
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181
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Galushko M, Frerich G, Perrar KM, Golla H, Radbruch L, Nauck F, Ostgathe C, Voltz R. Desire for hastened death: how do professionals in specialized palliative care react? Psychooncology 2015; 25:536-43. [DOI: 10.1002/pon.3959] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 08/04/2015] [Accepted: 08/10/2015] [Indexed: 11/10/2022]
Affiliation(s)
- M. Galushko
- Center for Palliative Medicine; University Hospital of Cologne; Köln Germany
| | - G. Frerich
- Center for Palliative Medicine; University Hospital of Cologne; Köln Germany
| | - K. M. Perrar
- Center for Palliative Medicine; University Hospital of Cologne; Köln Germany
- Center for Integrated Oncology; (CIO); Köln/Bonn Germany
| | - H. Golla
- Center for Palliative Medicine; University Hospital of Cologne; Köln Germany
- Center for Integrated Oncology; (CIO); Köln/Bonn Germany
| | - L. Radbruch
- Department of Palliative Medicine; University Hospital Bonn; Bonn Germany
- Palliative Care Center; Malteser Hospital Seliger Gerhard Bonn/Rhein-Sieg; Bonn Germany
- Center for Integrated Oncology; (CIO); Köln/Bonn Germany
| | - F. Nauck
- Departmentof Palliative Medicine; University Hospital; Göttingen Germany
| | - C. Ostgathe
- Division of Palliative Medicine & Comprehensive Cancer Center, CCC Erlangen-EMN; University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; Erlangen Germany
| | - R. Voltz
- Center for Palliative Medicine; University Hospital of Cologne; Köln Germany
- Center for Integrated Oncology; (CIO); Köln/Bonn Germany
- Clinical Trials Center Cologne; (ZKS); Köln Germany
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182
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DiMartino LD, Weiner BJ, Mayer DK, Jackson GL, Biddle AK. Do palliative care interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review. J Palliat Med 2015; 17:1384-99. [PMID: 25115197 DOI: 10.1089/jpm.2014.0092] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Frequent emergency department (ED) visits are an indicator of poor quality of cancer care. Coordination of care through the use of palliative care teams may limit aggressive care and improve outcomes for patients with cancer at the end of life. OBJECTIVES To systematically review the literature to determine whether palliative care interventions implemented in the hospital, home, or outpatient clinic are more effective than usual care in reducing ED visits among patients with cancer at the end of life. ELIGIBILITY CRITERIA PubMed, EMBASE, and CINAHL databases were searched from database inception to May 7, 2014. Only randomized/non-randomized controlled trials (RCTs) and observational studies examining the effect of palliative care interventions on ED visits among adult patients with cancer with advanced disease were considered. DATA EXTRACTION AND DATA SYNTHESIS Data were abstracted from the articles that met all the inclusion criteria. A second reviewer independently abstracted data from 2 articles and discrepancies were resolved. From 464 abstracts, 2 RCTs, 10 observational studies, and 1 non-RCT/quasi-experimental study were included. Overall there is limited evidence to support the use of palliative care interventions to reduce ED visits, although studies examining effect of hospice care and those conducted outside of the United States reported a statistically significant reduction in ED visits. CONCLUSIONS Evidence regarding whether palliative care interventions implemented in the hospital, home or outpatient clinic are more effective than usual care at reducing ED visits is not strongly substantiated based on the literature reviewed. Improvements in the quality of reporting for studies examining the effect of palliative care interventions on ED use are needed.
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Affiliation(s)
- Lisa D DiMartino
- 1 Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
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183
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Mistry B, Bainbridge D, Bryant D, Tan Toyofuku S, Seow H. What matters most for end-of-life care? Perspectives from community-based palliative care providers and administrators. BMJ Open 2015; 5:e007492. [PMID: 26124510 PMCID: PMC4486948 DOI: 10.1136/bmjopen-2014-007492] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES There has been little research conducted to understand the essential meaning of quality, community-based, end-of-life (EOL) care, despite the expansion of these services. The purpose of this study was to define what matters most for EOL care from the perspective of a diverse range of palliative care providers in the community who have daily encounters with death and dying. METHODS We used interviews to explore the perceptions of providers and administrators from 14 specialised palliative care teams in Ontario, Canada. Participants were prompted with the question 'What matters most for EOL care?' Responses were analysed using a phenomenological approach to derive themes depicting the universal essence of EOL care. RESULTS Data from 107 respondents were obtained and analysed, from which 40 formulated concepts emerged; these were further grouped into 9 themes. Of the respondents, 39% were nurses, 19% physicians, 27% were supervisors or executives and 15% other. The most predominate concept was that Patient's Wishes are Fulfilled, cited by almost half the respondents. The most prominent themes were Addressing the Non-physical Needs, Healthcare Teams' Nature of Palliative Care Delivery, Patient Wishes are Honoured, Addressing the Physical Needs, Preparing for and Accepting Death, Communication and Relationship Development, and Involving and Supporting the Family. CONCLUSIONS 9 critical domains of EOL care evolved from the interviews, indicating that quality EOL care extends beyond managing physical pain, but includes a holistic perspective of care, a healthcare team dedicated to the EOL journey and a patient-centred pathway. Tailoring the provision of care to consider these important elements plays a critical role in supporting a positive EOL experience for patients and families.
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Affiliation(s)
- Bina Mistry
- Cancer Care Ontario, Toronto, Ontario, Canada
| | - Daryl Bainbridge
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada Escarpment Cancer Research Institute, Hamilton, Ontario, Canada
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Gilson AM. Good state policy may not mean good pain care, but policy improvement offers hope for further progress: response to the Wahowiak article. J Pain Palliat Care Pharmacother 2015; 29:169-72. [PMID: 26095490 DOI: 10.3109/15360288.2015.1035838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Lindsey Wahowiak's late-2014 article discussing the status of pain management in the United States references findings from the University of Wisconsin Pain & Policy Studies Group's (PPSG) policy evaluation reports as supporting her conclusions. This commentary clarifies that the PPSG reports do not gauge the extent of pain care in each state, but rather how they relate to the quality of policies governing such treatment. This commentary also further supports Ms. Wahowiak's emphasis that influencing clinical pain outcomes is multifaceted and requires a multifaceted response. Importantly, policy change, along with its broad and continued communication and implementation, should be considered as only one of many crucial elements in providing quality pain management.
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185
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Darlow B, Coleman K, McKinlay E, Donovan S, Beckingsale L, Gray B, Neser H, Perry M, Stanley J, Pullon S. The positive impact of interprofessional education: a controlled trial to evaluate a programme for health professional students. BMC MEDICAL EDUCATION 2015; 15:98. [PMID: 26041132 PMCID: PMC4462076 DOI: 10.1186/s12909-015-0385-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 05/29/2015] [Indexed: 05/04/2023]
Abstract
BACKGROUND Collaborative interprofessional practice is an important means of providing effective care to people with complex health problems. Interprofessional education (IPE) is assumed to enhance interprofessional practice despite challenges to demonstrate its efficacy. This study evaluated whether an IPE programme changed students' attitudes to interprofessional teams and interprofessional learning, students' self-reported effectiveness as a team member, and students' perceived ability to manage long-term conditions. METHODS A prospective controlled trial evaluated an eleven-hour IPE programme focused on long-term conditions' management. Pre-registration students from the disciplines of dietetics (n = 9), medicine (n = 36), physiotherapy (n = 12), and radiation therapy (n = 26) were allocated to either an intervention group (n = 41) who received the IPE program or a control group (n = 42) who continued with their usual discipline specific curriculum. Outcome measures were the Attitudes Toward Health Care Teams Scale (ATHCTS), Readiness for Interprofessional Learning Scale (RIPLS), the Team Skills Scale (TSS), and the Long-Term Condition Management Scale (LTCMS). Analysis of covariance compared mean post-intervention scale scores adjusted for baseline scores. RESULTS Mean post-intervention attitude scores (all on a five-point scale) were significantly higher in the intervention group than the control group for all scales. The mean difference for the ATHCTS was 0.17 (95 %CI 0.05 to 0.30; p = 0.006), for the RIPLS was 0.30 (95 %CI 0.16 to 0.43; p < 0.001), for the TSS was 0.71 (95 %CI 0.49 to 0.92; p < 0.001), and for the LTCMS was 0.75 (95 %CI 0.56 to 0.94; p < 0.001). The mean effect of the intervention was similar for students from the two larger disciplinary sub-groups of medicine and radiation therapy. CONCLUSIONS An eleven-hour IPE programme resulted in improved attitudes towards interprofessional teams and interprofessional learning, as well as self-reported ability to function within an interprofessional team, and self-reported confidence, knowledge, and ability to manage people with long-term conditions. These findings indicate that a brief intervention such as this can have immediate positive effects and contribute to the development of health professionals who are ready to collaborate with others to improve patient outcomes.
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Affiliation(s)
- Ben Darlow
- Department Primary Health Care and General Practice, University of Otago, Wellington, PO Box 7343, Wellington South, New Zealand.
- Department of Radiation Therapy, University of Otago, Wellington, PO Box 7343, Wellington South, New Zealand.
| | - Karen Coleman
- Department of Radiation Therapy, University of Otago, Wellington, PO Box 7343, Wellington South, New Zealand.
| | - Eileen McKinlay
- Department Primary Health Care and General Practice, University of Otago, Wellington, PO Box 7343, Wellington South, New Zealand.
| | - Sarah Donovan
- Department Primary Health Care and General Practice, University of Otago, Wellington, PO Box 7343, Wellington South, New Zealand.
| | - Louise Beckingsale
- Department of Human Nutrition, University of Otago, Wellington, PO Box 7343, Wellington South, New Zealand.
| | - Ben Gray
- Department Primary Health Care and General Practice, University of Otago, Wellington, PO Box 7343, Wellington South, New Zealand.
| | - Hazel Neser
- Department of Radiation Therapy, University of Otago, Wellington, PO Box 7343, Wellington South, New Zealand.
| | - Meredith Perry
- School of Physiotherapy, University of Otago, Wellington, PO Box 7343, Wellington South, New Zealand.
| | - James Stanley
- Biostatistical Group, University of Otago, Wellington, PO Box 7343, Wellington South, New Zealand.
| | - Sue Pullon
- Department Primary Health Care and General Practice, University of Otago, Wellington, PO Box 7343, Wellington South, New Zealand.
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Bainbridge D, Seow H, Sussman J, Pond G, Barbera L. Factors associated with not receiving homecare, end-of-life homecare, or early homecare referral among cancer decedents: A population-based cohort study. Health Policy 2015; 119:831-9. [DOI: 10.1016/j.healthpol.2014.11.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 10/27/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
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Impact of admission to hospice on pain intensity and type of pain therapies administered. Support Care Cancer 2015; 24:225-232. [DOI: 10.1007/s00520-015-2768-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 05/12/2015] [Indexed: 12/25/2022]
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Beernaert K, Deliens L, De Vleminck A, Devroey D, Pardon K, Van den Block L, Cohen J. Is There a Need for Early Palliative Care in Patients With Life-Limiting Illnesses? Interview Study With Patients About Experienced Care Needs From Diagnosis Onward. Am J Hosp Palliat Care 2015; 33:489-97. [PMID: 25852203 DOI: 10.1177/1049909115577352] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The early integration of specialist palliative care has been shown to benefit the quality of life of patients with advanced cancer. In order to explore whether other seriously ill people and people at even earlier phases would also benefit from early palliative care, we conducted 18 qualitative interviews with people having cancer, chronic obstructive lung disease, heart failure, or dementia at different phases of the illness trajectory about how they experienced care needs related to their disease from diagnosis onward. Respondents experienced needs within the different domains of palliative care at different stages of the illness and different illness types or duration of the illness. This study contributes to the understanding of primary care needs of patients for whom palliative care (not necessarily specialized palliative care) could be beneficial.
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Affiliation(s)
- Kim Beernaert
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Aline De Vleminck
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Dirk Devroey
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Koen Pardon
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Joachim Cohen
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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Daveson BA, Smith M, Yi D, McCrone P, Grande G, Todd C, Gysels M, Costantini M, Murtagh FE, Higginson IJ, Evans CJ. The effectiveness and cost-effectiveness of inpatient specialist palliative care in acute hospitals for adults with advanced illness and their caregivers. Cochrane Database Syst Rev 2015. [DOI: 10.1002/14651858.cd011619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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191
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Brinkman-Stoppelenburg A, Onwuteaka-Philipsen BD, van der Heide A. Involvement of supportive care professionals in patient care in the last month of life. Support Care Cancer 2015; 23:2899-906. [PMID: 25733001 PMCID: PMC4552770 DOI: 10.1007/s00520-015-2655-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 02/08/2015] [Indexed: 11/28/2022]
Abstract
Background In the last month of life, many patients suffer from multiple symptoms and problems. Professional supportive care involvement may help to alleviate patients’ suffering and provide them with an optimal last phase of life. Purpose We investigated how often palliative care consultants, pain specialists, psychological experts and spiritual caregivers are involved in caring for patients in the last month of life, and which factors are associated with their involvement. Methods Questionnaires were mailed to physicians who had attended the death of a patient from a stratified sample of 8496 deaths that had occurred in 2010 in the Netherlands. The response rate was 74 % (n = 6263). Results A palliative care team or consultant had been involved in the last month of life in 12 % of all patients for whom death was expected; this percentage was 3 % for pain specialists, 6 % for psychologists or psychiatrists and 13 % for spiritual caregivers. Involvement of palliative care or pain specialists was most common in younger patients, in patients with cancer and in patients who died at home. Involvement of psychological or spiritual caregivers was most common in older patients, in females, in patients with dementia and in patients who died in a nursing home. Involvement of supportive caregivers was also associated with the use of morphine and end-of-life decisions. Conclusion Supportive care professionals are involved in end-of-life care in about a quarter of all non-suddenly dying patients. Their involvement is related to the setting where patients die, to the patient’s characteristics and to complex ethical decision-making.
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Affiliation(s)
- Arianne Brinkman-Stoppelenburg
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, Room NA22-12, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands,
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Dhiliwal SR, Muckaden M. Impact of specialist home-based palliative care services in a tertiary oncology set up: a prospective non-randomized observational study. Indian J Palliat Care 2015; 21:28-34. [PMID: 25709182 PMCID: PMC4332123 DOI: 10.4103/0973-1075.150170] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Home-based specialist palliative care services are developed to meet the needs of the patients in advanced stage of cancer at home with physical symptoms and distress. Specialist home care services are intended to improve symptom control and quality of life, enable patients to stay at home, and avoid unnecessary hospital admission. MATERIALS AND METHODS Total 690 new cases registered under home-based palliative care service in the year 2012 were prospectively studied to assess the impact of specialist home-based services using Edmonton symptom assessment scale (ESAS) and other parameters. RESULTS Out of the 690 registered cases, 506 patients received home-based palliative care. 50.98% patients were cared for at home, 28.85% patients needed hospice referral and 20.15% patients needed brief period of hospitalization. All patients receiving specialist home care had good relief of physical symptoms (P < 0.005). 83.2% patients received out of hours care (OOH) through liaising with local general practitioners; 42.68% received home based bereavement care and 91.66% had good bereavement outcomes. CONCLUSION Specialist home-based palliative care improved symptom control, health-related communication and psychosocial support. It promoted increased number of home-based death, appropriate and early hospice referral, and averted needless hospitalization. It improved bereavement outcomes, and caregiver satisfaction.
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Affiliation(s)
- Sunil R Dhiliwal
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Maryann Muckaden
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Govina O, Kotronoulas G, Mystakidou K, Katsaragakis S, Vlachou E, Patiraki E. Effects of patient and personal demographic, clinical and psychosocial characteristics on the burden of family members caring for patients with advanced cancer in Greece. Eur J Oncol Nurs 2015; 19:81-8. [DOI: 10.1016/j.ejon.2014.06.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 06/12/2014] [Accepted: 06/22/2014] [Indexed: 11/17/2022]
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Catania G, Beccaro M, Costantini M, Ugolini D, De Silvestri A, Bagnasco A, Sasso L. Effectiveness of complex interventions focused on quality-of-life assessment to improve palliative care patients' outcomes: a systematic review. Palliat Med 2015; 29:5-21. [PMID: 24938651 DOI: 10.1177/0269216314539718] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND One of the most crucial palliative care challenges is in determining how patient' needs are defined and assessed. Assessing quality of life has been defined as a priority in palliative care, and it has become a central concept in palliative care practice. AIM To determine to what extent interventions focused on measuring quality of life in palliative care practice are effective in improving outcomes in palliative care patients. DESIGN Systematic review according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and hand searches. DATA SOURCES MEDLINE, CINAHL, EMBASE, PsycINFO, and the Cochrane Library were searched for articles published until June 2012, and through hand searching from references lists of included articles. Only studies that included adult palliative care patients, in any palliative care clinical practice setting of care, and with an experimental, quasi-experimental, or observational analytical study design were eligible for inclusion. All studies were independently reviewed by two investigators who scored them for methodological quality by using the Edwards Method Score. RESULTS In total, 11 articles (of 8579) incorporating information from 10 studies were included. Only three were randomized controlled trials. The quality of the evidence was found from moderate to low. Given a wide variability among patients' outcomes, individual effect size (ES) was possible for 6 out of 10 studies, 3 of which found a moderate ES on symptoms (ES = 0.68) and psychological (ES = 0.60) and social (ES = 0.55) dimensions. CONCLUSION Effectiveness of interventions focused on quality-of-life assessment is moderate. Additional studies should explore the complexity of the real palliative care world more accurately and understand the effects of independent variables included in complex palliative care interventions.
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Affiliation(s)
- Gianluca Catania
- U.O.S. Regional Palliative Care Network, IRCCS Azienda Ospedaliera Universitaria San Martino-IST-Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Monica Beccaro
- Academy of Sciences of Palliative Medicine, Bologna, Italy
| | - Massimo Costantini
- Palliative Care Unit, IRCCS Arcispedale S Maria Nuova, Reggio Emilia, Italy
| | - Donatella Ugolini
- Department of Internal Medicine, University of Genoa, Genoa, Italy Unit of Clinical Epidemiology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST-Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | | | | | - Loredana Sasso
- Department of Health Sciences, University of Genoa, Genoa, Italy
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Abstract
OBJECTIVES To describe the evidence that palliative care, provided concurrently with disease-modifying treatment early in the course of a cancer diagnosis, can improve quality of life, length of survival, symptom burden, mood, and utilization of health services. DATA SOURCES Current research, the National Consensus Guidelines for Quality Palliative Care, and the American Society of Clinical Oncology Provisional Opinion on Integrating Palliative Care into Standard Oncology Care. CONCLUSION Despite recommendations and evidence, only a subset of cancer centers and community-based oncology clinics currently implement palliative care into ambulatory disease-focused cancer care. IMPLICATIONS FOR NURSING PRACTICE Oncology nurses can improve access by becoming knowledgeable about generalist palliative care and by advocating for local and national practice change.
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196
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West E, Costantini M, Pasman HR, Onwuteaka-Philipsen B. A comparison of drugs and procedures of care in the Italian hospice and hospital settings: the final three days of life for cancer patients. BMC Health Serv Res 2014; 14:496. [PMID: 25410710 PMCID: PMC4219049 DOI: 10.1186/s12913-014-0496-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 10/06/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND A palliative approach at the end of life typically involves forgoing certain drugs and procedures and starting others - weighing burden against potential benefit. An assessment of the palliative approach may be undertaken by investigating which drugs and procedures are used in the dying phase, and at what frequencies. METHODS Drugs were classified as potentially (in)appropriate based on expert classification. Procedures were classed as therapeutic or diagnostic. 271 consecutive cancer deaths from across 16 hospital general wards and 5 hospices in Italy gathered data on drugs and procedures in the final three days of life through a standardised form. Differences between the two groups were tested using chi-square testing, and logistic regressions were performed to control for patient characteristics. RESULTS 75.0% of patients in hospital received 3 or more potentially inappropriate drugs in their last three days of life, against 42.6% in hospice. Diagnostic procedures were carried out more frequently in hospital. Multivariate logistic regression showed that when data was controlled for patient characteristics, setting had a unique contribution to the differences found in use of drugs and procedures. CONCLUSION The data indicates a need for improvement in the hospital setting concerning recognising the need for palliative care, and ensuring a timely introduction of this approach.
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Affiliation(s)
- Emily West
- />Department of Public and Occupational Health, EMGO + Institute for Health and Care Research – Expertise Centre for Palliative Care, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
| | - Massimo Costantini
- />Palliative Care Unit, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - H Roeline Pasman
- />Department of Public and Occupational Health, EMGO + Institute for Health and Care Research – Expertise Centre for Palliative Care, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
| | - Bregje Onwuteaka-Philipsen
- />Department of Public and Occupational Health, EMGO + Institute for Health and Care Research – Expertise Centre for Palliative Care, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
| | - on behalf of EURO IMPACT
- />Department of Public and Occupational Health, EMGO + Institute for Health and Care Research – Expertise Centre for Palliative Care, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- />Palliative Care Unit, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
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Erlenwein J, Geyer A, Schlink J, Petzke F, Nauck F, Alt-Epping B. Characteristics of a palliative care consultation service with a focus on pain in a German university hospital. BMC Palliat Care 2014; 13:45. [PMID: 25276095 PMCID: PMC4177373 DOI: 10.1186/1472-684x-13-45] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 09/03/2014] [Indexed: 11/30/2022] Open
Abstract
Background A minority of patients with incurable and advanced disease receive specialised palliative care. Specialised palliative care services that complement the care of difficult and complex cases ought to be integrated with services that deliver general care for most patients. A typical setting in which this integrative concept takes place is the hospital setting, where patients suffering from incurable and advanced disease are treated in many different departments. The aim of the study is to investigate the profile and spectrum of a palliative care consultation service (PCCS) at a German university hospital with special reference to pain therapy. Methods We retrospectively analysed the PCCS documentation of three years. Results Most patients were referred from non-surgical departments, 72% were inpatients, and 28% were outpatients. 98% of the patients suffered from cancer. Counselling in pain therapy was one of the key aspects of the consultation: For 76% of all consulted patients, modifications of the analgesic regimen were recommended, which involved opioids in 96%. Recommendations on breakthrough-pain medication were made for 70% of the patients; this was an opioid in most cases (68%). The most commonly used opioid was morphine. For 17% of the patients, additional diagnostic procedures were recommended. Besides pain management palliative care consultation implied a wide range of recommendations and services: In addition to organising home care infrastructure, palliative care services supported patients and their families in understanding the life-limiting diseases. They also coordinated physical therapy and social and legal advice. Conclusion This survey clearly shows that for a consultation service to support patients with incurable or advanced disease, a multi-disciplinary approach is necessary to meet the complex requirements of a needs-adapted palliative care in inpatient or outpatient settings. Timely integration of palliative expertise may support symptom control and may give the required advice to patients, their carers, and their families.
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Affiliation(s)
- Joachim Erlenwein
- Department of Pain Medicine, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Georg-August-University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Almut Geyer
- Department of Palliative Medicine, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Georg-August-University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Julia Schlink
- Department of Pain Medicine, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Georg-August-University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Frank Petzke
- Department of Pain Medicine, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Georg-August-University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Friedemann Nauck
- Department of Palliative Medicine, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Georg-August-University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Bernd Alt-Epping
- Department of Palliative Medicine, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Georg-August-University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
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Delgado Guay MO, Guay MOD, Tanzi S, San Miguel Arregui MT, Arregui MTSM, Chisholm G, De la Cruz MG, de la Cruz M, Bruera E. Characteristics and outcomes of advanced cancer patients who miss outpatient supportive care consult appointments. Support Care Cancer 2014; 22:2869-74. [PMID: 24771301 DOI: 10.1007/s00520-014-2254-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 04/09/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Missed appointments (MA) are frequent, but there are no studies on the effects of the first MA at supportive care outpatient clinics on clinical outcomes. METHODS We determined the frequency of MA among all patients referred to our clinic from January-December 2011 and recorded the clinical and demographic data and outcomes of 218 MA patients and 217 consecutive patients who kept their first appointments (KA). RESULTS Of 1,352 advanced-cancer patients referred to our clinic, 218 (16 %) had an MA. The MA patients' median age was 57 years (interquartile range, 49-67). The mean time between referral and appointment was 7.4 days (range, 0-71) for KA patients vs. 9.1 days (range, 0-89) for MA patients (P = 0.006). Reasons for missing included admission to the hospital (17/218 [8 %]), death (4/218 [2 %]), appointments with primary oncologists (37/218 [18 %]), other appointments (19/218 [9 %]), visits to the emergency room (ER) (9/218 [9 %]), and unknown (111/218 [54 %]). MA patients visited the ER more at 2 weeks (16/214 [7 %] vs. 5/217 [2 %], P = 0.010) and 4 weeks (17/205 [8 %] vs. 8/217 [4 %], P = 0.060). Median-survival duration for MA patients was 177 days (range, 127-215) vs. 253 days (range, 192-347) for KA patients (P = 0.013). Multivariate analysis showed that MAs were associated with longer time between referral and scheduled appointment (odds ratio [OR], 1.026/day, P = 0.030), referral from targeted therapy services (OR, 2.177, P = 0.004), living in Texas/Louisiana regions (OR, 2.345, P = 0.002), having an advanced directive (OR, 0.154, P < 0.0001), and being referred for symptom control (OR, 0.024, P = 0.0003). CONCLUSION MA patients with advanced cancer have worse survival and increased ER utilization than KA patients. Patients at higher risk for MA should undergo more aggressive follow-up. More research is needed.
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Affiliation(s)
- Marvin Omar Delgado Guay
- Palliative Care and Rehabilitation Medicine, Unit 1414, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030-4009, USA,
| | - Marvin Omar Delgado Guay
- Palliative Care and Rehabilitation Medicine, Unit 1414, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030-4009, USA,
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Lefkowits C, Sukumvanich P, Claxton R, Courtney-Brooks M, Kelley JL, McNeil MA, Goodman A. Needs assessment of palliative care education in gynecologic oncology fellowship: we're not teaching what we think is most important. Gynecol Oncol 2014; 135:255-60. [PMID: 25135001 DOI: 10.1016/j.ygyno.2014.08.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/01/2014] [Accepted: 08/09/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We sought to characterize gynecologic oncology fellowship directors' perspectives on (1) inclusion of palliative care (PC) topics in current fellowship curricula, (2) relative importance of PC topics and (3) interest in new PC curricular materials. METHODS An electronic survey was distributed to fellowship directors, assessing current teaching of 16 PC topics meeting ABOG/ASCO objectives, relative importance of PC topics and interest in new PC curricular materials. Descriptive and correlative statistics were used. RESULTS Response rate was 63% (29/46). 100% of programs had coverage of some PC topic in didactics in the past year and 48% (14/29) have either a required or elective PC rotation. Only 14% (4/29) have a written PC curriculum. Rates of explicit teaching of PC topics ranged from 36% (fatigue) to 93% (nausea). Four of the top five most important PC topics for fellowship education were communication topics. There was no correlation between topics most frequently taught and those considered most important (rs=0.11, p=0.69). All fellowship directors would consider using new PC curricular materials. Educational modalities of greatest interest include example teaching cases and PowerPoint slides. CONCLUSIONS Gynecologic oncology fellowship directors prioritize communication topics as the most important PC topics for fellows to learn. There is no correlation between which PC topics are currently being taught and which are considered most important. Interest in new PC curricular materials is high, representing an opportunity for curricular development and dissemination. Future efforts should address identification of optimal methods for teaching communication to gynecologic oncology fellows.
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Affiliation(s)
- Carolyn Lefkowits
- Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
| | - Paniti Sukumvanich
- Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Rene Claxton
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care & Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Madeleine Courtney-Brooks
- Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Joseph L Kelley
- Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Melissa A McNeil
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Annekathryn Goodman
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Bush SH, Kanji S, Pereira JL, Davis DHJ, Currow DC, Meagher D, Rabheru K, Wright D, Bruera E, Hartwick M, Gagnon PR, Gagnon B, Breitbart W, Regnier L, Lawlor PG. Treating an established episode of delirium in palliative care: expert opinion and review of the current evidence base with recommendations for future development. J Pain Symptom Manage 2014; 48:231-248. [PMID: 24480529 PMCID: PMC4081457 DOI: 10.1016/j.jpainsymman.2013.07.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/24/2013] [Accepted: 07/31/2013] [Indexed: 12/20/2022]
Abstract
CONTEXT Delirium is a highly prevalent complication in patients in palliative care settings, especially in the end-of-life context. OBJECTIVES To review the current evidence base for treating episodes of delirium in palliative care settings and propose a framework for future development. METHODS We combined multidisciplinary input from delirium researchers and other purposely selected stakeholders at an international delirium study planning meeting. This was supplemented by a literature search of multiple databases and relevant reference lists to identify studies regarding therapeutic interventions for delirium. RESULTS The context of delirium management in palliative care is highly variable. The standard management of a delirium episode includes the investigation of precipitating and aggravating factors followed by symptomatic treatment with drug therapy. However, the intensity of this management depends on illness trajectory and goals of care in addition to the local availability of both investigative modalities and therapeutic interventions. Pharmacologically, haloperidol remains the practice standard by consensus for symptomatic control. Dosing schedules are derived from expert opinion and various clinical practice guidelines as evidence-based data from palliative care settings are limited. The commonly used pharmacologic interventions for delirium in this population warrant evaluation in clinical trials to examine dosing and titration regimens, different routes of administration, and safety and efficacy compared with placebo. CONCLUSION Delirium treatment is multidimensional and includes the identification of precipitating and aggravating factors. For symptomatic management, haloperidol remains the practice standard. Further high-quality collaborative research investigating the appropriate treatment of this complex syndrome is needed.
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Affiliation(s)
- Shirley H Bush
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Salmaan Kanji
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - José L Pereira
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Daniel H J Davis
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - David C Currow
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - David Meagher
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Kiran Rabheru
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - David Wright
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Eduardo Bruera
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Michael Hartwick
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Pierre R Gagnon
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Bruno Gagnon
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - William Breitbart
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Laura Regnier
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Peter G Lawlor
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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