201
|
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.
Collapse
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
| |
Collapse
|
202
|
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.
Collapse
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
| |
Collapse
|
203
|
May P, Normand C, Morrison RS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med 2014; 17:1054-63. [PMID: 24984168 DOI: 10.1089/jpm.2013.0594] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Maintaining the recent expansion of palliative care access in the United States is a recognized public health concern. Economic evaluation is essential to validate current provision and assess the case for new programs. Previous economic reviews in palliative care reported on programs across settings and systems; none has examined specifically the hospital consultative model, the dominant model of provision in the United States. OBJECTIVES To review systematically the economic evidence on specialist palliative care consultation teams in the hospital setting, to appraise this evidence critically, and to identify areas for future research in this field. DATA SOURCES A meta-review ("a review of existing reviews") was conducted of eight published systematic reviews and one relevant nonsystematic review. To identify articles published outside of the timeframe of these reviews, systematic searches were performed on the PubMed, CINAHL, and EconLit databases. STUDY SELECTION Articles were included if they compared the costs and/or cost effectiveness of a specialist hospital inpatient palliative care consultation for adult patients with those of a comparator. RESULTS Ten studies were included and these demonstrate a clear pattern of cost-saving impact from inpatient consultation programs. Nevertheless, knowledge gaps still exist regarding the economic effects of these programs. Current evidence has been generated from the hospital perspective; health system costs, patient and caregiver costs, and health outcomes are typically not included. CONCLUSIONS Inpatient palliative care consultation programs have been shown to save hospitals money and to provide improved care to patients with serious illness. With a clear pattern of cost-saving using current methodology, it is timely to begin expanding the scope of economic evaluation in this field. Future research must address the measurement of both costs and outcomes to understand more fully the role that palliative care plays in enhancing value in health care. Relevant domains for such research are identified.
Collapse
Affiliation(s)
- Peter May
- 1 Centre for Health Policy and Management, Trinity College Dublin , Ireland
| | | | | |
Collapse
|
204
|
Abstract
The provision of comprehensive cancer care in an increasingly complex landscape necessitates that oncology providers familiarize themselves with the application of palliative care. Palliative care is a learnable skill. Recent endeavors in this arena have demonstrated that providing palliative care is part and parcel with providing compassionate and high-quality cancer care, specifically as it pertains to physical and emotional outcomes for patients and their caregivers alike. The basic tenets of providing palliative care emphasize: frequent and honest communication, routine and systematic symptom assessment, integration of spiritual assessments, and early integration of specialized hospice and palliative care resources as a patient's circumstances evolve. This article will endeavor to review and synthesize recent developments in the palliative care literature, specifically as they pertain to the oncologist as a primary palliative care provider.
Collapse
|
205
|
Seow H, Brazil K, Sussman J, Pereira J, Marshall D, Austin PC, Husain A, Rangrej J, Barbera L. Impact of community based, specialist palliative care teams on hospitalisations and emergency department visits late in life and hospital deaths: a pooled analysis. BMJ 2014; 348:g3496. [PMID: 24906901 PMCID: PMC4048125 DOI: 10.1136/bmj.g3496] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To determine the pooled effect of exposure to one of 11 specialist palliative care teams providing services in patients' homes. DESIGN Pooled analysis of a retrospective cohort study. SETTING Ontario, Canada. PARTICIPANTS 3109 patients who received care from specialist palliative care teams in 2009-11 (exposed) matched by propensity score to 3109 patients who received usual care (unexposed). INTERVENTION The palliative care teams studied served different geographies and varied in team composition and size but had the same core team members and role: a core group of palliative care physicians, nurses, and family physicians who provide integrated palliative care to patients in their homes. The teams' role was to manage symptoms, provide education and care, coordinate services, and be available without interruption regardless of time or day. MAIN OUTCOME MEASURES Patients (a) being in hospital in the last two weeks of life; (b) having an emergency department visit in the last two weeks of life; or (c) dying in hospital. RESULTS In both exposed and unexposed groups, about 80% had cancer and 78% received end of life homecare services for the same average duration. Across all palliative care teams, 970 (31.2%) of the exposed group were in hospital and 896 (28.9%) had an emergency department visit in the last two weeks of life respectively, compared with 1219 (39.3%) and 1070 (34.5%) of the unexposed group (P<0.001). The pooled relative risks of being in hospital and having an emergency department visit in late life comparing exposed versus unexposed were 0.68 (95% confidence interval 0.61 to 0.76) and 0.77 (0.69 to 0.86) respectively. Fewer exposed than unexposed patients died in hospital (503 (16.2%) v 887 (28.6%), P<0.001), and the pooled relative risk of dying in hospital was 0.46 (0.40 to 0.52). CONCLUSIONS Community based specialist palliative care teams, despite variation in team composition and geographies, were effective at reducing acute care use and hospital deaths at the end of life.
Collapse
Affiliation(s)
- Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario L8V 5C2, Canada
| | - Kevin Brazil
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Jonathan Sussman
- Department of Oncology, McMaster University, Hamilton, Ontario L8V 5C2, Canada
| | - José Pereira
- Division of Palliative Care, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Denise Marshall
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter C Austin
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Amna Husain
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jagadish Rangrej
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Lisa Barbera
- Department of Radiation Oncology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
206
|
Clinical presentation and patterns of care for short-term survivors of malignant glioma. J Neurooncol 2014; 119:333-41. [PMID: 24889839 DOI: 10.1007/s11060-014-1483-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 05/14/2014] [Indexed: 10/25/2022]
Abstract
Palliative care provision for patients with high-grade malignant glioma is often under-utilised. Difficulties in prognostication and inter-patient variability in survival may limit timely referral. This study sought to (1) describe the clinical presentation of short-term survivors of malignant glioma (survival time <120 days); (2) map their hospital utilisation, including palliative and supportive care service use, and place of death; (3) identify factors which may be important to serve as a prompt for palliative care referral. A retrospective cohort study of incident malignant glioma cases between 2003-2009 surviving <120 days in Victoria, Australia was undertaken (n = 482). Cases were stratified according to the patient's survival status (dead vs. alive) at the end of the diagnosis admission, and at 120 days from diagnosis. Palliative care was received by 78 % of patients who died during the diagnosis admission. Only 12 % of patients who survived the admission and then deteriorated rapidly dying in the following 120 days were referred to palliative care in their hospital admission, suggesting an important clinical subgroup that may miss out on being linked into palliative care services. The strongest predictor of death during the diagnosis admission was the presence of cognitive or behavioural symptoms, which may be an important prompt for early palliative care referral.
Collapse
|
207
|
Bailey FA, Williams BR, Woodby LL, Goode PS, Redden DT, Houston TK, Granstaff US, Johnson TM, Pennypacker LC, Haddock KS, Painter JM, Spencer JM, Hartney T, Burgio KL. Intervention to improve care at life's end in inpatient settings: the BEACON trial. J Gen Intern Med 2014; 29:836-43. [PMID: 24449032 PMCID: PMC4026508 DOI: 10.1007/s11606-013-2724-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings. OBJECTIVE To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings. DESIGN Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design. PARTICIPANTS Six Veterans Affairs Medical Centers (VAMCs). INTERVENTION Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools. MAIN MEASURES Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n = 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends. KEY RESULTS Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints. CONCLUSIONS This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.
Collapse
Affiliation(s)
- F. Amos Bailey
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - Beverly R. Williams
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - Lesa L. Woodby
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - Patricia S. Goode
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - David T. Redden
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - Thomas K. Houston
- />Department of Veterans Affairs, VA eHealth Quality Enhancement Research Initiative, Bedford, MA USA
- />University of Massachusetts Medical School, Worcester, MA USA
| | - U. Shanette Granstaff
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - Theodore M. Johnson
- />Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Decatur, GA USA
- />Emory University, Atlanta, GA USA
| | | | - K. Sue Haddock
- />William Jennings Bryan Dorn VA Medical Center, Columbia, SC USA
| | | | | | | | - Kathryn L. Burgio
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| |
Collapse
|
208
|
Haun MW, Estel S, Rücker G, Friederich HC, Thomas M, Hartmann M. Early palliative care for improving quality of life and survival time in adults with advanced cancer. Cochrane Database Syst Rev 2014. [DOI: 10.1002/14651858.cd011129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
209
|
Affiliation(s)
- Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA 02215, USA; Harvard Medical School Center for Palliative Care, Boston, MA, USA.
| | - J Andrew Billings
- Harvard Medical School Center for Palliative Care, Boston, MA, USA; Cambridge Health Alliance, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
210
|
Amano K, Morita T, Tatara R, Katayama H, Aiki S, Kitada N, Fumimoto H, Sato E. Assessment of Intervention by a Palliative Care Team Working in a Japanese General Hospital. Am J Hosp Palliat Care 2014; 32:600-3. [DOI: 10.1177/1049909114532340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Our objective was to explore the effectiveness of a palliative care team (PCT) by investigating potential differences in opioid prescription between patients who had had PCT involvement before admission to an inpatient hospice and those who had not. A total of 221 patients met the criteria; they were divided into an intervention group (n = 140) and a control group (n = 81). The daily dose of opioid before admission to the hospice was significantly higher in the intervention group ( P < .001). The difference between the maximum opioid dose and the initial dose, the rate of increase in opioids until death, and the length of stay in the hospice were not significantly different between the groups. A PCT contributes to more appropriate use of opioids before admission to a hospice.
Collapse
Affiliation(s)
- Koji Amano
- Department of Palliative Medicine, Palliative Care Team, Osaka City General Hospital, Osaka, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team and Seirei Hospice, Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Ryohei Tatara
- Department of Palliative Medicine, Palliative Care Team, Osaka City General Hospital, Osaka, Japan
| | - Hirofumi Katayama
- Department of Palliative Medicine, Osaka City General Hospital, Osaka, Japan
| | - Sayo Aiki
- Department of Palliative Medicine, Osaka City General Hospital, Osaka, Japan
| | - Namiki Kitada
- Palliative Care Team, Osaka City General Hospital, Osaka, Japan
| | - Hiromi Fumimoto
- Palliative Care Team, Osaka City General Hospital, Osaka, Japan
| | - Emi Sato
- Palliative Care Team, Osaka City General Hospital, Osaka, Japan
| |
Collapse
|
211
|
Goldenheim A, Oates D, Parker V, Russell M, Winter M, Silliman RA. Rehospitalization of older adults discharged to home hospice care. J Palliat Med 2014; 17:841-4. [PMID: 24708490 DOI: 10.1089/jpm.2013.0224] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Acute hospital readmission of older adults receiving hospice care is not aligned with hospice goals. OBJECTIVE To identify factors associated with 30-day readmission among older adults newly discharged to hospice. DESIGN/SUBJECTS Medical record review of 59 patients, 19 readmitted within 30 days and 40 randomly selected controls not readmitted, from 206 patients newly discharged to home hospice care between February 1, 2005 and January 31, 2010. Measures/Analysis: Information was collected about hospital course, end-of-life planning, and posthospitalization follow-up. We calculated bivariate associations and developed a Cox Proportional Hazards model examining the relation between index admission characteristics and readmission. RESULTS Patients' mean age was 79.7±8.4; 74.6% were female; 52.5% were black. Among those readmitted, 25% had received a palliative care consultation, compared to 47.1% of those not readmitted (p=0.06). Patients without a participating decision-maker involved in their hospice decision had 3.5 times the risk of readmission within 30 days, compared to those with (hazard ratio [HR] 3.53, confidence interval [CI] 0.97, 12.82). Patients who had one or more telephone contacts with their primary care physician (PCP) during week 1 after discharge had 2.4 times the readmission risk within 30 days, compared to patients with no such contacts during this period (HR 2.35, CI 0.9, 6.1). CONCLUSIONS Readmission within 30 days of initial discharge to hospice is associated with several measures of care and care planning. Further study of these measures may identify opportunities for interventions to improve the hospital-to-hospice transition and to decrease hospital readmissions.
Collapse
Affiliation(s)
- Anna Goldenheim
- 1 Boston University School of Medicine , Boston, Massachusetts
| | | | | | | | | | | |
Collapse
|
212
|
Luckett T, Phillips J, Agar M, Virdun C, Green A, Davidson PM. Elements of effective palliative care models: a rapid review. BMC Health Serv Res 2014; 14:136. [PMID: 24670065 PMCID: PMC3986907 DOI: 10.1186/1472-6963-14-136] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 03/10/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Population ageing, changes to the profiles of life-limiting illnesses and evolving societal attitudes prompt a critical evaluation of models of palliative care. We set out to identify evidence-based models of palliative care to inform policy reform in Australia. METHOD A rapid review of electronic databases and the grey literature was undertaken over an eight week period in April-June 2012. We included policy documents and comparative studies from countries within the Organisation for Economic Co-operation and Development (OECD) published in English since 2001. Meta-analysis was planned where >1 study met criteria; otherwise, synthesis was narrative using methods described by Popay et al. (2006). RESULTS Of 1,959 peer-reviewed articles, 23 reported systematic reviews, 9 additional RCTs and 34 non-randomised comparative studies. Variation in the content of models, contexts in which these were implemented and lack of detailed reporting meant that elements of models constituted a more meaningful unit of analysis than models themselves. Case management was the element most consistently reported in models for which comparative studies provided evidence for effectiveness. Essential attributes of population-based palliative care models identified by policy and addressed by more than one element were communication and coordination between providers (including primary care), skill enhancement, and capacity to respond rapidly to individuals' changing needs and preferences over time. CONCLUSION Models of palliative care should integrate specialist expertise with primary and community care services and enable transitions across settings, including residential aged care. The increasing complexity of care needs, services, interventions and contextual drivers warrants future research aimed at elucidating the interactions between different components and the roles played by patient, provider and health system factors. The findings of this review are limited by its rapid methodology and focus on model elements relevant to Australia's health system.
Collapse
Affiliation(s)
- Tim Luckett
- Improving Palliative Care through Clinical Trials (ImPaCCT), Sydney, NSW, Australia
- University of Technology Sydney (UTS), Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Jane Phillips
- University of Technology Sydney (UTS), Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia
- The Cunningham Centre for Palliative Care Sydney, Sacred Heart Hospice, Sydney, NSW, Australia
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
| | - Meera Agar
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
- HammondCare, Sydney, NSW, Australia
- The Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
| | - Claudia Virdun
- University of Technology Sydney (UTS), Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia
| | - Anna Green
- University of Technology Sydney (UTS), Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia
| | - Patricia M Davidson
- University of Technology Sydney (UTS), Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia
- School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
213
|
Lin E, Rosenthal MA, Eastman P, Le BH. Inpatient palliative care consultation for patients with glioblastoma in a tertiary hospital. Intern Med J 2014; 43:942-5. [PMID: 23919337 DOI: 10.1111/imj.12211] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 01/25/2013] [Indexed: 11/27/2022]
Abstract
Glioblastoma (GBM) is an uncommon disease with significant mortality and morbidity, but there is a lack of published evidence on palliative care involvement with this population. This audit highlights the heavy symptom burden, extensive allied health involvement and discharge outcomes of GBM inpatients referred to the palliative care service at The Royal Melbourne Hospital. This information can provide an important framework for further research and also supports the role of multidisciplinary palliative care in the care of patients with GBM.
Collapse
Affiliation(s)
- E Lin
- Department of Palliative Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia.
| | | | | | | |
Collapse
|
214
|
Psychologists involved in cancer palliative care in Japan: A nationwide survey. Palliat Support Care 2014; 13:327-34. [DOI: 10.1017/s1478951514000029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractObjective:The aim of this study was to clarify, using a nationwide survey, what is perceived as necessary knowledge and skills for psychologists involved in cancer palliative care in Japan, the expectations of medical staff members, and the degree to which these expectations are met.Method:We conducted a questionnaire survey of psychologists involved in cancer palliative care. A total of 419 psychologists from 403 facilities were asked to fill out the questionnaire and return it anonymously. Some 401 psychologists (89 males, 310 females, and 2 unspecified; mean age, 37.2 ± 9.5 years) responded about necessary knowledge and skills for psychologists working in cancer palliative care, the necessity for training, expectations at their current workplace, and the degree to which expectations are met.Results:More than 90% of participants responded that many kinds of knowledge and skills related to the field of cancer palliative care are necessary. Over 80% of participants indicated a necessity for training related to these knowledge and skills. Although more than 50% (range, 50.1–85.8%) of participants responded that such services as “cooperation with medical staff within a hospital,” “handling patients for whom psychological support would be beneficial,” and “assessment of patients' mental state” were expected at their workplace, fewer than 60% (31.4–56.9%) responded that they actually performed these roles.Significance of Results:Our results show that many psychologists in cancer palliative care feel unable to respond to the expectations at their current workplace and that they require more adequate knowledge and skills related to cancer palliative care to work effectively. No other nationwide surveys have generated this type of information in Japan, so we believe that the results of our study are uniquely important.
Collapse
|
215
|
Sasahara T, Watakabe A, Aruga E, Fujimoto K, Higashi K, Hisahara K, Hori N, Ikenaga M, Izawa T, Kanai Y, Kinoshita H, Kobayakawa M, Kobayashi K, Kohara H, Namba M, Nozaki-Taguchi N, Osaka I, Saito M, Sekine R, Shinjo T, Suga A, Tokuno Y, Yamamoto R, Yomiya K, Morita T. Assessment of reasons for referral and activities of hospital palliative care teams using a standard format: a multicenter 1000 case description. J Pain Symptom Manage 2014; 47:579-587.e6. [PMID: 23972575 DOI: 10.1016/j.jpainsymman.2013.04.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 04/09/2013] [Accepted: 04/19/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT The many benefits of hospital palliative care teams (PCTs) are well known. However, their specific activities have not been fully clarified, and no standardized methods for reporting PCT activities are available. OBJECTIVES The aim of this study was to investigate, through the use of a standard format, the activities performed by hospital PCTs in Japan. METHODS This was a prospective observational study. A total of 21 hospital PCTs were included in this study, and each recruited approximately 50 consecutively referred patients. Participating PCTs filled in a standard form for reporting activities. RESULTS We obtained data from 1055 patients who were referred to PCTs. Of the 1055 patients, 1005 patients (95%) had cancer. The median number of reasons for referral and problems identified by PCTs was two (0-22) and four (0-18), respectively. The two major reasons for referral were pain (63%) and anxiety/depression/grief/emotional burden (22%). The major recommendations were pharmacological treatment (74%), care for the patient's physical symptoms (49%), and support for patient's decision making (38%). The major activities performed by the PCTs were comprehensive assessment (90%), care for the patient's physical symptoms (77%), and pharmacological treatment (74%). CONCLUSION The components of hospital PCT activities were successfully measured using the Standard Format for Reporting Hospital PCT Activity. The results of this study and the format for reporting hospital PCT activity could be effective in improving hospital PCT practice and for the education of new hospital PCT members.
Collapse
Affiliation(s)
- Tomoyo Sasahara
- Division of Health Innovation and Nursing, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
| | | | - Etsuko Aruga
- Department of Palliative Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Koji Fujimoto
- Palliative Care Team, Seirei Mikatahara General Hospital, Shizuoka, Japan
| | | | - Ko Hisahara
- Department of Palliative Care, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Natsuki Hori
- Palliative Care Unit, NTT Medical Center Tokyo, Tokyo, Japan
| | - Masayuki Ikenaga
- Children's Hospice Hospital, Yodogawa Christian Hospital, Osaka, Japan
| | | | | | - Hiroya Kinoshita
- Department of Palliative Medicine, National Cancer Center Hospital, East, Chiba, Japan
| | - Makoto Kobayakawa
- Palliative Care Team, Hiroshima University Hospital, Hiroshima, Japan
| | | | - Hiroyuki Kohara
- Department of Palliative Care, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | | | - Natsuko Nozaki-Taguchi
- Department of Anesthesiology and Palliative Medicine, Chiba University Hospital, Chiba, Japan
| | - Iwao Osaka
- Division of Palliative Medicine, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Mari Saito
- Division of Chemotherapy and Palliative Care, Yokohama City University Medical Center, Kanagawa, Japan
| | | | - Takuya Shinjo
- Palliative Care Unit, Shakaihoken Kobe Central Hospital, Hyogo, Japan
| | - Akihiko Suga
- Department of Palliative Medicine, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
| | | | - Ryo Yamamoto
- Department of General Internal Medicine, Saku Central Hospital, Nagano, Japan
| | - Kinomi Yomiya
- Department of Palliative Care, Saitama Cancer Center, Saitama, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team and Seirei Hospice, Seirei Mikatahara General Hospital, Shizuoka, Japan
| |
Collapse
|
216
|
Partinico M, Corà A, Ghisi M, Ouimet AJ, Visentin M. A new Italian questionnaire to assess caregivers of cancer patients' satisfaction with palliative care: multicenter validation of the post mortem questionnaire-short form. J Pain Symptom Manage 2014; 47:298-306. [PMID: 23856096 DOI: 10.1016/j.jpainsymman.2013.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 03/18/2013] [Accepted: 03/29/2013] [Indexed: 11/16/2022]
Abstract
CONTEXT Caregiver satisfaction with palliative care is a crucial indicator of its effectiveness. In light of the lack of validated or reliable Italian instruments, the Post Mortem Questionnaire-Short Form (QPM-SF), a self-report questionnaire, has been developed to assess home and inpatient hospice care. OBJECTIVES The present study was designed to evaluate the psychometric properties of QPM-SF and assess for differences in quality of palliative care between hospice and home care settings. METHODS A total of 584 caregivers of terminal cancer patients completed QPM-SF one month after the death of the care recipient. To assess test-retest reliability, a subgroup of 50 caregivers completed the questionnaire a second time, one month later. RESULTS QPM-SF showed good internal consistency and temporal stability and a four-factor structure: "Integrated home care," "Hospice," "Physical care-Information-Global evaluation," and "Needs." CONCLUSION QPM-SF may be considered a valid, reliable, and well-accepted self-report instrument for examining and implementing palliative care interventions.
Collapse
Affiliation(s)
| | - Alice Corà
- Psychology Unit, San Bortolo Hospital, Vicenza, Italy
| | - Marta Ghisi
- Department of General Psychology, University of Padova, Padua, Italy
| | - Allison J Ouimet
- Department of Psychology, Concordia University, Montreal, Quebec, Canada
| | - Marco Visentin
- Pain Therapy and Palliative Care Unit, San Bortolo Hospital, Vicenza, Italy
| | | |
Collapse
|
217
|
Johnston B, Buchanan D, Papadopoulou C, Sandeman G, Lord H. Integrating palliative care in lung cancer: an early feasibility study. Int J Palliat Nurs 2014; 19:433-7. [PMID: 24071834 DOI: 10.12968/ijpn.2013.19.9.433] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM The aim of this preliminary study was to evaluate the feasibility of conducting an effectiveness trial of early access to palliative care services for people with lung cancer through use of an integrated outpatient model. METHODS Newly diagnosed patients with lung cancer receiving palliative-intent treatment or best supportive care treatment were recruited over a 5-month period from one out-patient clinic in Scotland. Patients were offered a clinical review appointment with a palliative medicine consultant at two time points: baseline and 12 weeks later. Prior to each appointment patients completed three outcome measures addressing symptom severity, wellbeing, and health-care needs. One-to-one interviews were also conducted to explore patients' experiences of being involved in the study. RESULTS Three patients participated in the study. The main reasons for low recruitment were patients' deteriorating condition and unwillingness to undertake extra hospital visits. However, qualitative data indicated that the participants found this extra layer of supportive care useful in identifying and managing their needs, as well as enabling future planning. CONCLUSION Further testing is needed to ascertain the feasibility of conducting a trial of integrating early access to palliative care services into routine practice for people with lung cancer.
Collapse
Affiliation(s)
- Bridget Johnston
- Reader in Palliative Care, University of Dundee, School of Nursing and Midwifery, Dundee, Scotland, and Honorary Nurse Consultant (Palliative Care) NHS Tayside
| | | | | | | | | |
Collapse
|
218
|
Hodge DR, Salas-Wright CP, Wolosin RJ. Addressing Spiritual Needs and Overall Satisfaction With Service Provision Among Older Hospitalized Inpatients. J Appl Gerontol 2014; 35:374-400. [DOI: 10.1177/0733464813515090] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 11/04/2013] [Indexed: 12/22/2022] Open
Abstract
Little research has examined the relationship between addressing older adults’ spiritual needs and overall satisfaction with service provision during hospitalization, despite the importance of spirituality and religion to most older adults. This study examined this relationship, in tandem with the effects of eight potential mediators. Toward this end, structural equation modeling was used with a sample of 4,112 adults age 65 and older who were consecutively discharged over a 12-month period from hospitals in California, Texas, and New England. As hypothesized, addressing spiritual needs was positively associated with overall satisfaction. The relationship between spiritual needs and satisfaction was fully mediated by seven variables: nursing staff, the discharge process, visitors, physicians, the admissions process, room quality, and the administration of tests and treatments. The diverse array of mediating pathways identified highlights the importance of health care practitioners working collaboratively to address older adults’ spiritual needs.
Collapse
|
219
|
Imai K, Ikenaga M, Kodama T, Kamura L, Tamura K, Takeohara M, Takashita T, Morita T. Effectiveness of the etiology-based antiemetic recommendations by a palliative care team for nausea in cancer patients. ACTA ACUST UNITED AC 2014. [DOI: 10.2512/jspm.9.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
220
|
Costantini M, Pellegrini F, Di Leo S, Beccaro M, Rossi C, Flego G, Romoli V, Giannotti M, Morone P, Ivaldi GP, Cavallo L, Fusco F, Higginson IJ. The Liverpool Care Pathway for cancer patients dying in hospital medical wards: a before-after cluster phase II trial of outcomes reported by family members. Palliat Med 2014; 28:10-7. [PMID: 23652840 DOI: 10.1177/0269216313487569] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hospital is the most common place of cancer death but concerns regarding the quality of end-of-life care remain. AIM Preliminary assessment of the effectiveness of the Liverpool Care Pathway on the quality of end-of-life care provided to adult cancer patients during their last week of life in hospital. DESIGN Uncontrolled before-after intervention cluster trial. SETTINGS/PARTICIPANTS The trial was performed within four hospital wards participating in the pilot implementation of the Italian version of the Liverpool Care Pathway programme. All cancer patients who died in the hospital wards 2-4 months before and after the implementation of the Italian version of Liverpool Care Pathway were identified. A total of 2 months after the patient's death, bereaved family members were interviewed using the Toolkit After-Death Family Interview (seven 0-100 scales assessing the quality of end-of-life care) and the Italian version of the Views of Informal Carers - Evaluation of Services (VOICES) (three items assessing pain, breathlessness and nausea-vomiting). RESULTS An interview was obtained for 79 family members, 46 (73.0%) before and 33 (68.8%) after implementation of the Italian version of Liverpool Care Pathway. Following Italian version of Liverpool Care Pathway implementation, there was a significant improvement in the mean scores of four Toolkit scales: respect, kindness and dignity (+16.8; 95% confidence interval = 3.6-30.0; p = 0.015); family emotional support (+20.9; 95% confidence interval = 9.6-32.3; p < 0.001); family self-efficacy (+14.3; 95% confidence interval = 0.3-28.2; p = 0.049) and coordination of care (+14.3; 95% confidence interval = 4.2-24.3; p = 0.007). No significant improvement in symptom' control was observed. CONCLUSIONS These results provide the first robust data collected from family members of a preliminary clinically significant improvement, in some aspects, of quality of care after the implementation of the Italian version of Liverpool Care Pathway programme. The poor effect for symptom control suggests areas for further innovation and development.
Collapse
Affiliation(s)
- Massimo Costantini
- 1Regional Palliative Care Network, IRCCS AOU San Martino-IST, Genoa, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
221
|
Evans CJ, Harding R, Higginson IJ. 'Best practice' in developing and evaluating palliative and end-of-life care services: a meta-synthesis of research methods for the MORECare project. Palliat Med 2013; 27:885-98. [PMID: 23322647 DOI: 10.1177/0269216312467489] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Improved and cost-effective palliative and end-of-life care is an international policy imperative. Developments are impeded by a weak and often inconsistent evidence base. AIM To examine the main methodological challenges and limitations to developing and evaluating palliative and end-of-life care services and requirements to further this field of research. DESIGN A meta-synthesis to systematically appraise the evidence from systematic reviews on the research methods used in studies evaluating the effectiveness of palliative care services for patients with advanced illness and/or carers meeting inclusion and quality criteria. We extracted data from the reviews on the methodological issues reported on the included studies into Excel spreadsheets and generated textual descriptions coded and analysed in NVivo. DATA SOURCES Six electronic databases, reference chaining and expert advice. RESULTS In total, 27 systematic reviews were included on the effectiveness of palliative care services for patients with cancer (n = 6), advanced illness (n = 10) or mixed populations (n = 11) across care settings. Main methodological challenges were implementation as a continuum, active precise recruitment, addressing randomisation and economic evaluation beyond cost savings. CONCLUSIONS The complexity of delivering and evaluating palliative and end-of-life care services requires the accumulation of knowledge from multiple sources to understand the active components of an intervention to deliver patient benefit and examine the evaluation methods to detect change and reveal processes prior to a definitive trial. The implementation of evidence into practice should form a continuum throughout the evaluation stages to reveal understanding on the process of intervention delivery, the context and the intended outcome(s).
Collapse
Affiliation(s)
- Catherine J Evans
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | | | | |
Collapse
|
222
|
Evans CJ, Benalia H, Preston NJ, Grande G, Gysels M, Short V, Daveson BA, Bausewein C, Todd C, Higginson IJ. The selection and use of outcome measures in palliative and end-of-life care research: the MORECare International Consensus Workshop. J Pain Symptom Manage 2013; 46:925-37. [PMID: 23628515 PMCID: PMC3858887 DOI: 10.1016/j.jpainsymman.2013.01.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 01/16/2013] [Accepted: 01/28/2013] [Indexed: 11/21/2022]
Abstract
CONTEXT A major barrier to widening and sustaining palliative care service provision is the requirement for better selection and use of outcome measures. Service commissioning is increasingly based on patient, carer, and service outcomes as opposed to service activity. OBJECTIVES To generate recommendations and consensus for research in palliative and end-of-life care on the properties of the best outcome measures, enhancing the validity of proxy-reported data and optimal data collection time points. METHODS An international expert "workshop" was convened and an online consensus survey was undertaken using the MORECare Transparent Expert Consultation to generate recommendations and level of agreement. We focused on three areas: 1) measurement properties, 2) use of proxies, and 3) measurement timing. Data analysis comprised descriptive analysis of aggregate scores and collation of narrative comments. RESULTS There were 31 workshop attendees; 29 recommendations were included in the online survey, completed by 28 experts. The top three recommendations by area were the following: 1) the properties of the best outcome measures are responsive to change over time and capture clinically important data, 2) to enhance the validity of proxy data requires clear and specific guidelines to aid lay individuals' and/or professionals' completion of proxy measures, and 3) data collection time points need clear identification to establish a baseline. CONCLUSION Outcome measurement in palliative and end-of-life care requires the use of psychometrically robust measures that are clinically responsive, with defined data collection time points to establish a baseline and clear administration guidelines to complete proxy measures. To further the field requires clinical imperatives to more closely inform recommendations on outcome measurement.
Collapse
Affiliation(s)
- Catherine J Evans
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, United Kingdom.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
223
|
Cardoso DH, Muniz RM, Schwartz E, Arrieira ICDO. Cuidados paliativos na assistência hospitalar: a vivência de uma equipe multiprofissional. TEXTO & CONTEXTO ENFERMAGEM 2013. [DOI: 10.1590/s0104-07072013000400032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Trata-se de um estudo qualitativo, exploratório e descritivo, que objetivou conhecer a vivência de uma equipe multiprofissional no cuidado paliativo no contexto hospitalar. Participaram do estudo seis membros de uma equipe multiprofissional de saúde, que atende pacientes em cuidados paliativos, de um Hospital Escola no Sul do Brasil. Identificou-se que os profissionais, ao iniciarem sua trajetória de cuidado na terminalidade, referiram frustração e impotência. Contudo, a experiência fez com que encontrassem novos significados para o cuidado prestado, passando a entender a morte como evento natural da vida e a importância de garantir qualidade de vida e conforto ao paciente. Os participantes relataram a necessidade do fortalecimento da comunicação, do trabalho em equipe e de um espaço para discutirem a terminalidade. Assim, a atenção hospitalar deve atender as necessidades do paciente em cuidados paliativos e família, articulando e promovendo ações que garantam o alívio dos sofrimentos e uma sobrevida digna.
Collapse
|
224
|
|
225
|
Howie L, Peppercorn J. Early palliative care in cancer treatment: rationale, evidence and clinical implications. Ther Adv Med Oncol 2013; 5:318-23. [PMID: 24179486 DOI: 10.1177/1758834013500375] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Patients with advanced cancer often experience symptoms of disease and treatment that contribute to distress and diminish their quality of life (QOL). Care that is aimed at control of these symptoms, whether or not the patient is undergoing ongoing disease-directed therapy to control the cancer, is thus a key feature of high-quality patient-centered care. In standard oncology practice, it is easy for focus on this type of care to be obscured by discussions and management of anticancer therapy and adequate attention to QOL, patient preferences, and goals of care often occur only days to weeks from the patient's death. The initiation of palliative care and discussion of the patients' goals and preferences earlier in the course of disease can lead to improved symptom control, reduced distress throughout the disease-directed therapy, and care delivery that matches the patients' preferences. This review discusses the evolving evidence for early initiation of palliative care in patients with advanced cancer and ongoing barriers to care in this setting. We highlight challenges for research and care delivery and the potential for broader awareness of the demonstrated benefits of palliative care to help translate known benefits into improved outcomes for patients facing advanced cancer.
Collapse
Affiliation(s)
- Lynn Howie
- Associate Professor of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | | |
Collapse
|
226
|
Greer JA, Jackson VA, Meier DE, Temel JS. Early integration of palliative care services with standard oncology care for patients with advanced cancer. CA Cancer J Clin 2013; 63:349-63. [PMID: 23856954 DOI: 10.3322/caac.21192] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 04/01/2013] [Accepted: 04/02/2013] [Indexed: 12/25/2022] Open
Abstract
Scientific advances in novel cancer therapeutics have led to remarkable changes in oncology practice and longer lives for patients diagnosed with incurable malignancies. However, the myriad options for treatment have established a culture of cancer care that has not been matched with a similar availability of efficacious supportive care interventions aimed at relieving debilitating symptoms due to progressive disease and treatment side effects. Accumulating data show that the introduction of palliative care services at the time of diagnosis of advanced cancer leads to meaningful improvement in the experiences of patients and family caregivers by emphasizing symptom management, quality of life, and treatment planning. In this review article, the rationale and evidence base for this model of early palliative care services integrated into standard oncology care are presented. In addition, the implications and limitations of the existing data to 1) elucidate the mechanisms by which early palliative care benefits patients and families; 2) guide the dissemination and application of this model in outpatient settings; and 3) inform health care policy regarding the delivery of high-quality, cost-effective, and comprehensive cancer care are discussed.
Collapse
Affiliation(s)
- Joseph A Greer
- Assistant Professor of Psychology, Harvard Medical School, and Assistant in Psychology, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | | | | | | |
Collapse
|
227
|
Bhatraju P, Friedenberg AS, Uppal A, Evans L. Factors Associated With Utilization of an Inpatient Palliative Care Consultation Service in an Urban Public Hospital. Am J Hosp Palliat Care 2013; 31:641-4. [DOI: 10.1177/1049909113502845] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: To evaluate factors associated with palliative care consultation (PCC) in an urban public hospital. Methods: A retrospective chart review of patients who died on inpatient medical services. Results: Patients with a PCC were more likely to have a “do not resuscitate” (DNR) order at the time of death (p<0.001) and had a decreased likelihood of death in the ICU (p<0.001). Factors associated with PCC in a multivariate analysis included: cancer diagnosis (p=0.01), at least a high school education (p=0.04), older age (p=.003), and birth outside the US (p=0.03). Conclusion: The increased PCC utilization for immigrants is in contrast to previously reported literature. This increased use may be because access to services in a municipal hospital is not driven by demographic and socioeconomic factors.
Collapse
Affiliation(s)
- Pavan Bhatraju
- Department of Medicine, New York University, New York City, NY, USA
| | | | - Amit Uppal
- Department of Medicine, New York University, New York City, NY, USA
| | - Laura Evans
- Department of Medicine, New York University, New York City, NY, USA
| |
Collapse
|
228
|
Morita T, Sato K, Miyashita M, Akiyama M, Kato M, Kawagoe S, Kinoshita H, Shirahige Y, Yamakawa S, Yamada M, Eguchi K. Exploring the perceived changes and the reasons why expected outcomes were not obtained in individual levels in a successful regional palliative care intervention trial: an analysis for interpretations. Support Care Cancer 2013; 21:3393-402. [PMID: 23934223 DOI: 10.1007/s00520-013-1910-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 07/12/2013] [Indexed: 11/29/2022]
Abstract
CONTEXT The Japan Outreach Palliative Care Trial of Integrated Model (OPTIM) study, a mixed-methods study to evaluate the effects of a comprehensive regional palliative care program, revealed that the program provided broad positive outcomes at the regional level: increased home death, palliative care use, patient- and family-reported qualities of care, and health care professionals' difficulties. Not all participants however obtained positive outcomes and thus exploring the reasons why expected outcomes were observed in individual levels could be of value. AIMS The primary aims were to explore why expected outcomes were not obtained in individual participants, and the perceived changes in daily practices of physicians and nurses were explored. SUBJECTS AND METHODS Postintervention questionnaire survey on 857 patients, 1,137 bereaved family members, 706 physicians, and 2,236 nurses were analyzed. RESULTS The reasons for not achieving home deaths included unexpected rapid deterioration, caregivers unavailable, concerns about adequate responses to sudden changes, and physical symptoms uncontrolled, while lack of physician availability at home and lack of information from physicians were less frequently reported. The reasons for not receiving specialized palliative care services were the lack of recommendations from physicians and no information about palliative care services. The reason for evaluating the quality of palliative care as not high was that clinicians tried to relieve symptoms, but there were limited effects and insufficient time. Many physicians and nurses reported that they became more aware of palliative care, that the availability of palliative care specialists and knowledge about palliative care improved, and that they cooperated with other regional health care providers more easily. CONCLUSION The OPTIM study seemed to succeed in optimizing physician availability at home, improves physician information about home care, achieved maximum efforts to relieve patient distress by clinicians, and increased communication among regional health care professionals. To achieve further better outcomes, multiple interventions to the health care system to be performed on the basis of a comprehensive regional palliative care program are proposed.
Collapse
Affiliation(s)
- Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, 433-8558, Japan,
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
229
|
Ford DW, Koch KA, Ray DE, Selecky PA. Palliative and end-of-life care in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e498S-e512S. [PMID: 23649453 DOI: 10.1378/chest.12-2367] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In the United States, lung cancer is a major health problem that is associated with significant patient distress and often limited survival, with some exceptions. The purpose of this article is to address the role of palliative and end-of-life care in the management of patients with lung cancer and to address the need for good communication skills to provide support to patients and families. METHODS This article is based on an extensive review of the medical literature up to April 2012, with some articles as recent as August 2012. The authors used the PubMed and Cochrane databases, as well as EBESCO Host search, for articles addressing palliative care, supportive care, lung neoplasm, and quality of life in cancer or neoplasm, with no limitation on dates. The research was limited to human studies and the English language. RESULTS There was no "definitive" work in this area, most of it being concurrence based rather than evidence based. Several randomized controlled trials were identified, which are reviewed in the text. The article focuses on the assessment and treatment of suffering in patients with lung cancer, as well as the importance of communication in the care of these patients over the course of the disease. The aim of medical care for patients with terminal lung cancer is to decrease symptom burden, enhance the quality of remaining life, and increase survival benefit. A second objective is to emphasize the importance of good communication skills when addressing the needs of the patient and his or her family, starting at the time of diagnosis, which in itself is a life-changing event. Too often we do it poorly, but by using patient-centered communication skills, the outcome can be more satisfactory. Finally, the article addresses the importance of advance care planning for patients with lung cancer, from the time of diagnosis until the last phase of the illness, and it is designed to enhance the physician's role in facilitating this planning process. CONCLUSIONS This article provides guidance on how to reduce patient distress and avoid nonbeneficial treatment in patients with lung cancer. The goal is to decrease symptom burden, enhance quality of life, and increase survival benefit. Good communication and advance care planning are vital to the process.
Collapse
Affiliation(s)
- Dee Walker Ford
- Division of Pulmonary, Critical Care Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, SC.
| | | | | | | |
Collapse
|
230
|
Gallagher R, Krawczyk M. Family members' perceptions of end-of-life care across diverse locations of care. BMC Palliat Care 2013; 12:25. [PMID: 23870101 PMCID: PMC3750390 DOI: 10.1186/1472-684x-12-25] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 07/18/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The goal of the study was to assess perceived level of satisfaction with end-of-life care, focusing on the last 48 hours of life. METHODS A previously validated instrument was used in a telephone survey with bereaved family members (n=90) of patients who died within an organization in British Columbia. RESULTS Bereaved family members had many unmet needs for information about the patient's changing condition, the process of dying, how symptoms would be managed and what to do at the time of death. In addition, many bereaved relatives felt that the patient or resident had an unmet need for emotional support and that their own emotional needs were not addressed adequately. The last place of care had the most significant effect on all of these variables, with acute care and residential care having the most unmet needs. Hospice had the fewest unmet needs, followed by the palliative and the intensive care units. CONCLUSIONS We discuss these findings in relation to overall satisfaction with care, focus on individual, ethno-cultural and diversity issues, information and decision-making, symptom management and attending to the family. We conclude by offering possible practices address the end-of-life needs of patients and family members.
Collapse
Affiliation(s)
- Romayne Gallagher
- Division of Palliative Care, Department of Family and Community Medicine, Providence Health Care, University of British Columbia.
| | | |
Collapse
|
231
|
Referral to palliative care in COPD and other chronic diseases: a population-based study. Respir Med 2013; 107:1731-9. [PMID: 23810150 DOI: 10.1016/j.rmed.2013.06.003] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 05/29/2013] [Accepted: 06/03/2013] [Indexed: 11/24/2022]
Abstract
AIM To describe how patients with COPD, heart failure, dementia and cancer differ in frequency and timing of referral to palliative care services. METHODS We performed a population-based study with the Sentinel Network of General Practitioners in Belgium. Of 2405 registered deaths respectively 5%, 4% and 28% were identified as from COPD, heart failure or cancer and 14% were diagnosed with severe dementia. GPs reported use and timing of palliative care services and treatment goals in the final three months of life. RESULTS Patients with COPD (20%) were less likely than those with heart failure (34%), severe dementia (37%) or cancer (60%) to be referred to palliative care services (p < 0.001). The median days between referral and death was respectively 10, 12, 14 and 20. Patients with COPD who were not referred more often received treatment with a curative or life-prolonging goal and less often with a palliative or comfort goal than did the other patients who were not referred. CONCLUSION Patients with COPD are underserved in terms of palliative care compared to those with other chronic life-limiting diseases. Awareness of palliative care as an option for patients with COPD needs to increase in palliative care services, physicians and the general public.
Collapse
|
232
|
Lin E, Rosenthal MA, Le BH, Eastman P. Neuro-oncology and palliative care: a challenging interface. Neuro Oncol 2013; 14 Suppl 4:iv3-7. [PMID: 23095828 DOI: 10.1093/neuonc/nos209] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Esther Lin
- Department of Palliative Care, The Royal Melbourne Hospital, Victoria, Australia.
| | | | | | | |
Collapse
|
233
|
Cost-effectiveness of early palliative care intervention in recurrent platinum-resistant ovarian cancer. Gynecol Oncol 2013; 130:426-30. [PMID: 23769759 DOI: 10.1016/j.ygyno.2013.06.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/05/2013] [Accepted: 06/06/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine if early palliative care intervention in patients with recurrent, platinum-resistant ovarian cancer is potentially cost saving or cost-effective. METHODS A decision model with a 6 month time horizon evaluated routine care versus routine care plus early referral to a palliative medicine specialist (EPC) for recurrent platinum-resistant ovarian cancer. Model parameters included rates of inpatient admissions, emergency department (ED) visits, chemotherapy administration, and quality of life (QOL). From published ovarian cancer data, we assumed baseline rates over the final 6 months: hospitalization 70%, chemotherapy 60%, and ED visit 30%. Published data from a randomized trial evaluating EPC in metastatic lung cancer were used to model odds ratios (ORs) for potential reductions in hospitalization (OR 0.69), chemotherapy (OR 0.77), and emergency department care (OR 0.74) and improvement in QOL (OR 1.07). The costs of hospitalization, ED visit, chemotherapy, and EPC were based on published data. Ranges were used for sensitivity analysis. Effectiveness was quantified in quality adjusted life years (QALYs); survival was assumed equivalent between strategies. RESULTS EPC was associated with a cost savings of $1285 per patient over routine care. In sensitivity analysis incorporating QOL, EPC was either dominant or cost-effective, with an incremental cost-effectiveness ratio (ICER) <$50,000/QALY, unless the cost of outpatient EPC exceeded $2400. Assuming no clinical benefit other than QOL (no change in chemotherapy administration, hospitalizations or ED visits), EPC remained highly cost-effective with ICER $37,440/QALY. CONCLUSION Early palliative care intervention has the potential to reduce costs associated with end of life care in patients with ovarian cancer.
Collapse
|
234
|
Hjermstad MJ, Kolflaath J, Løkken AO, Hanssen SB, Normann AP, Aass N. Are emergency admissions in palliative cancer care always necessary? Results from a descriptive study. BMJ Open 2013; 3:bmjopen-2012-002515. [PMID: 23793662 PMCID: PMC3669727 DOI: 10.1136/bmjopen-2012-002515] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Patients with advanced cancer are often admitted to hospital as emergency cases. This may not always be medically indicated. Study objectives were to register the reasons for the emergency admissions, to examine interventions performed during hospitalisation and self-reported symptom intensity at admission and discharge, and to assess patients' opinions about the admission. DESIGN This was a descriptive before-and-after study. Participating patients completed the Edmonton Symptom Assessment System (ESAS) twice, upon hospital admission and prior to discharge. All patients underwent a structured interview assessing their opinion about the emergency admission. Medical data were obtained from the hospital records. SETTING The study was performed in two Norwegian acute care secondary hospitals with urban catchment areas. PARTICIPANTS 44 patients with cancer (men 27 and women 17; mean age 69.2, SD 9.2) representing 50 emergency admissions were included. RESULTS Median length of stay was 7 days (95% CI 7.4 to 11.4). Median survival was 50 days (95% CI 51 to 115). 90% were admitted from home, and 46% had been hospitalised less than 1 month earlier. Lung and gastrointestinal symptoms and pain were the most frequent reasons for admissions. Mean pain scores on ESAS were reduced by 50% from admission to discharge (p<0.01). Simple interventions such as hydration, bladder catheterisation and oxygen therapy were most frequent. Nearly one-third would have preferred treatment at another site, provided that the quality of care was similar. Home visits by the family doctor and specialised care teams were perceived by patients as important to prevent hospitalisation. CONCLUSIONS In most emergency admissions, relatively simple medical interventions are necessary. Specialised care teams with palliative care physicians, easier access to the family doctor and better lines of cooperation between hospitals and the primary care sector may make it possible to perform more of these procedures at home, thereby reducing the need for emergency admissions.
Collapse
Affiliation(s)
- Marianne Jensen Hjermstad
- Department of Oncology, Regional Centre for Excellence in Palliative Care, Oslo University Hospital, Oslo, Norway
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, European Palliative Care Research Centre, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jan Kolflaath
- Department of Anaesthesiology, Østfold Hospital Trust, Fredrikstad, Norway
| | - Aud O Løkken
- Department of Anaesthesiology, Østfold Hospital Trust, Fredrikstad, Norway
| | - Sjur B Hanssen
- Department of Oncology, Regional Centre for Excellence in Palliative Care, Oslo University Hospital, Oslo, Norway
| | - Are P Normann
- Department of Medicine, Hospice Lovisenberg, Lovisenberg Diakonale Hospital, Oslo, Norway
| | - Nina Aass
- Department of Oncology, Regional Centre for Excellence in Palliative Care, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
235
|
Higginson IJ, Evans CJ, Grande G, Preston N, Morgan M, McCrone P, Lewis P, Fayers P, Harding R, Hotopf M, Murray SA, Benalia H, Gysels M, Farquhar M, Todd C. Evaluating complex interventions in end of life care: the MORECare statement on good practice generated by a synthesis of transparent expert consultations and systematic reviews. BMC Med 2013; 11:111. [PMID: 23618406 PMCID: PMC3635872 DOI: 10.1186/1741-7015-11-111] [Citation(s) in RCA: 227] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 04/02/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite being a core business of medicine, end of life care (EoLC) is neglected. It is hampered by research that is difficult to conduct with no common standards. We aimed to develop evidence-based guidance on the best methods for the design and conduct of research on EoLC to further knowledge in the field. METHODS The Methods Of Researching End of life Care (MORECare) project built on the Medical Research Council guidance on the development and evaluation of complex circumstances. We conducted systematic literature reviews, transparent expert consultations (TEC) involving consensus methods of nominal group and online voting, and stakeholder workshops to identify challenges and best practice in EoLC research, including: participation recruitment, ethics, attrition, integration of mixed methods, complex outcomes and economic evaluation. We synthesised all findings to develop a guidance statement on the best methods to research EoLC. RESULTS We integrated data from three systematic reviews and five TECs with 133 online responses. We recommend research designs extending beyond randomised trials and encompassing mixed methods. Patients and families value participation in research, and consumer or patient collaboration in developing studies can resolve some ethical concerns. It is ethically desirable to offer patients and families the opportunity to participate in research. Outcome measures should be short, responsive to change and ideally used for both clinical practice and research. Attrition should be anticipated in studies and may affirm inclusion of the relevant population, but careful reporting is necessitated using a new classification. Eventual implementation requires consideration at all stages of the project. CONCLUSIONS The MORECare statement provides 36 best practice solutions for research evaluating services and treatments in EoLC to improve study quality and set the standard for future research. The statement may be used alongside existing statements and provides a first step in setting common, much needed standards for evaluative research in EoLC. These are relevant to those undertaking research, trainee researchers, research funders, ethical committees and editors.
Collapse
Affiliation(s)
- Irene J Higginson
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessmer Road, Denmark Hill, London, SE5 9PJ, UK
| | - Catherine J Evans
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessmer Road, Denmark Hill, London, SE5 9PJ, UK
| | - Gunn Grande
- School of Nursing, Midwifery & Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Nancy Preston
- School of Nursing, Midwifery & Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Physics Avenue, Lancaster, LA1 4YT, UK
| | - Myfanwy Morgan
- Department of Primary Care and Public Health Sciences, King’s College London, Capital House, Weston Street, London, SE1 3QD, UK
| | - Paul McCrone
- Department of Health Services and Population Research, King’s College London, Institute of Psychiatry, 16 De Crespingy Park, London, SE5 8AF, UK
| | - Penney Lewis
- King’s College London, Centre of Medical Law and Ethics, Dickson Poon School of Law, Strand, London, WC2R 2LS, UK
| | - Peter Fayers
- Institute of Applied Health Sciences, University of Aberdeen, Cornhill Road, Aberdeen, AB25 2ZD, UK
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Prinsesse Kristinasgt. 1, NO-7006, Trondheim, Norway
| | - Richard Harding
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessmer Road, Denmark Hill, London, SE5 9PJ, UK
| | - Matthew Hotopf
- Department of Psychological Medicine, King’s College London, Institute of Psychiatry, Weston Education Centre, Cutcombe Rd, London, SE5 9RJ, UK
| | - Scott A Murray
- Primary Palliative Care Research Group, Centre for Population Health Sciences, University of Edinburgh, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Hamid Benalia
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessmer Road, Denmark Hill, London, SE5 9PJ, UK
| | - Marjolein Gysels
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessmer Road, Denmark Hill, London, SE5 9PJ, UK
- University of Amsterdam, Centre for Social Science and Global Health, Oudezijds Achterburgwal 185, Amsterdam, 1012 DK, The Netherlands
| | - Morag Farquhar
- Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Institute of Public Health, Forvie Site, Robinson Way, Cambridge, CB2 OSR, UK
| | - Chris Todd
- School of Nursing, Midwifery & Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| |
Collapse
|
236
|
|
237
|
Dy SM, Apostol C, Martinez KA, Aslakson RA. Continuity, coordination, and transitions of care for patients with serious and advanced illness: a systematic review of interventions. J Palliat Med 2013; 16:436-45. [PMID: 23488450 DOI: 10.1089/jpm.2012.0317] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Continuity, coordination, and transitions of care are key to high-quality medical care for patients with serious and advanced illness. We conducted a systematic review to evaluate the impact of interventions targeting these areas in this population. METHODS We searched PubMed, CINAHL, PsycINFO, Cochrane, and DARE from 2000 through 2011. We included prospective controlled studies targeting continuity, coordination, and transitions for patients with advanced illness that reported patient centered outcomes. Of 13,014 citations, 23 studies met inclusion criteria. Two investigators extracted and checked data on population, interventions, methods, outcomes, and methodological quality. RESULTS Four of the six studies evaluating patient satisfaction (67%) and four of the six studies evaluating caregiver satisfaction (67%) showed statistically significant improvements in these outcomes in the intervention compared to the control group. Only three of the nine studies (33%) measuring quality of life and five of the 16 (31%) measuring health care utilization showed improvement. Results were similar across different types of interventions. CONCLUSIONS Many studies were limited by methodologic issues such as use of measurement tools not developed for patients with advanced disease and small sample size. Interventions and outcomes were too heterogeneous for meta-analysis. We found moderate evidence that interventions targeting continuity, coordination, and transitions in patients with advanced and serious illness improve patient and caregiver satisfaction, but low evidence for other outcomes. Further research is needed on how to target these domains for outcomes such as health care utilization.
Collapse
Affiliation(s)
- Sydney M Dy
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
| | | | | | | |
Collapse
|
238
|
|
239
|
Tallman K, Greenwald R, Reidenouer A, Pantel L. Living with advanced illness: longitudinal study of patient, family, and caregiver needs. Perm J 2013; 16:28-35. [PMID: 23012596 DOI: 10.7812/tpp/12-029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Inpatient palliative care (IPC) consults are associated with improved quality of care and less intensive utilization. However, little is known about how the needs of patients with advanced illness and the needs of their families and caregivers evolve or how effectively those needs are addressed. The objectives of this study were 1) to summarize findings in the literature about the needs of patients with advanced illness and the needs of their families and caregivers; 2) to identify the primary needs of patients, families, and caregivers across the continuum of care from their vantage point; and 3) to learn how IPC teams affect the care experience. METHODS We used a longitudinal, video-ethnographic approach to observe and to interview 12 patients and their families before, during, and after an IPC consult at 3 urban medical centers. Additional interviews took place up to 12 months after discharge. RESULTS Five patient/family/caregiver needs were important to all family units. IPC teams responded effectively to a variety of needs that were not met in the hospital, but some postdischarge needs, beyond the scope of IPC or health care coverage, were not completely met. CONCLUSION Findings built upon the needs identified in the literature. The longitudinal approach highlighted changes in needs of patients, families, and caregivers in response to emerging medical and nonmedical developments, from their perspective. Areas for improvement include clear, integrated communications in the hospital and coordinated, comprehensive postdischarge support for patients not under hospice care and for their caregivers.
Collapse
Affiliation(s)
- Karen Tallman
- Center for Care Experience, Care Management Institute and The Permanente Federation, Oakland, CA, USA.
| | | | | | | |
Collapse
|
240
|
Luckett T, Davidson PM, Lam L, Phillips J, Currow DC, Agar M. Do community specialist palliative care services that provide home nursing increase rates of home death for people with life-limiting illnesses? A systematic review and meta-analysis of comparative studies. J Pain Symptom Manage 2013; 45:279-97. [PMID: 22917710 DOI: 10.1016/j.jpainsymman.2012.02.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 02/16/2012] [Accepted: 02/20/2012] [Indexed: 11/17/2022]
Abstract
CONTEXT Systematic reviews and meta-analyses suggest that community specialist palliative care services (SPCSs) can avoid hospitalizations and enable home deaths. But more information is needed regarding the relative efficacies of different models. Family caregivers highlight home nursing as the most important service, but it is also likely the most costly. OBJECTIVES To establish whether community SPCSs offering home nursing increase rates of home death compared with other models. METHODS We searched MEDLINE, AMED, Embase, CINAHL, the Cochrane Database of Systematic Reviews, and CENTRAL on March 2 and 3, 2011. To be eligible, articles had to be published in English-language peer-reviewed journals and report original research comparing the effect on home deaths of SPCSs providing home nursing vs. any alternative. Study quality was independently rated using Cochrane grades. Maximum likelihood estimation of heterogeneity was used to establish the method for meta-analysis (fixed or random effects). Potential biases were assessed. RESULTS Of 1492 articles screened, 10 articles were found eligible, reporting nine studies that yielded data for 10 comparisons. Study quality was high in two cases, moderate in three and low in four. Meta-analysis indicated a significant effect for SPCSs with home nursing (odds ratio 4.45, 95% CI 3.24-6.11; P<0.001). However, the high-quality studies found no effect (odds ratio 1.40, 95% CI 0.97-2.02; P=0.071). Bias was minimal. CONCLUSION A meta-analysis found evidence to be inconclusive that community SPCSs that offer home nursing increase home deaths without compromising symptoms or increasing costs. But a compelling trend warrants further confirmatory studies. Future trials should compare the relative efficacy of different models and intensities of SPCSs.
Collapse
Affiliation(s)
- Tim Luckett
- Improving Palliative Care through Clinical Trials (ImPaCCT), South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.
| | | | | | | | | | | |
Collapse
|
241
|
Al-Shahri MZ, Eldali AM, Al-Zahrani O. Nonpain Symptoms of New and Follow-up Cancer Patients Attending a Palliative Care Outpatient Clinic in Saudi Arabia. Indian J Palliat Care 2012; 18:98-102. [PMID: 23093824 PMCID: PMC3477372 DOI: 10.4103/0973-1075.100822] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Epidemiology of cancer-related nonpain symptoms receives less attention in literature as compared with cancer pain. OBJECTIVE This paper aims at exploring the prevalence and severity of nonpain symptoms in cancer patients attending a palliative care (PC) outpatient clinic. MATERIALS AND METHODS Over a 5 months period, consecutive adult cancer patients attending PC outpatient clinic at a tertiary hospital were evaluated for the presence and severity of 10 nonpain symptoms. Patients were grouped to new or follow-up cases and were also grouped according to performance status and cancer type. Prevalence and severity of symptoms were compared between groups using t test or analysis of variance as appropriate. RESULTS Fifty-one males and 73 females were interviewed. The most common cancer is female breast (27.4%) followed by head and neck (15.3%). Majority of patients (67%) were new to PC clinic. Patients had 5.1 nonpain symptoms on average, with most common symptoms being tiredness (79.8%), loss of appetite (71.8%), dry mouth (69.4%), anxiety (60.5%), and depression (50.8%). The least common symptoms were confusion and nausea (22.6% each). The median scores of severity were highest for tiredness, loss of appetite, dry mouth, and insomnia (5 points each). Symptoms were fewer among patients with good performance status (P = 0.002), whereas age, gender, cancer type, and encounter type were not associated with difference in symptom prevalence. Younger patients, females and those with poor performance status have shown a tendency toward higher severity scores for several symptoms. CONCLUSION The significant prevalence and severity of nonpain symptoms among new and follow-up cancer patients seen in a PC outpatient clinic emphasizes the need for comprehensive assessment and routinely audited symptom management plans.
Collapse
Affiliation(s)
- Mohammad Zafir Al-Shahri
- Department of Palliative Medicine, Oncology Centre, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | | |
Collapse
|
242
|
Smith TJ, Coyne PJ, Cassel JB. Practical guidelines for developing new palliative care services: resource management. Ann Oncol 2012; 23 Suppl 3:70-5. [PMID: 22628420 DOI: 10.1093/annonc/mds092] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The data are relatively clear cut that palliative care improves quality of life and symptom control, improves quality of care by reducing aggressive but unsuccessful end of life care, and reduces costs. That should be an easy message to deliver to the public, health care administrators, payers, and governments. In fact, the arguments to develop palliative care services must be clear and concise, and make the clinical and financial case for the services that the palliative care team wants to deliver. Here, we discuss some of the types of models including consult services, outpatient programs, and inpatient units; the important components; some easy to use screening tools; components of the consultation team; a model medical record that increases "prompts" to do best palliative care; and data to report to supervisors.
Collapse
Affiliation(s)
- T J Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medicine, 600 N.Wolfe Street, Baltimore, MD 21287-0005, USA.
| | | | | |
Collapse
|
243
|
Beydon L, Pelluchon C, Beloucif S, Baghdadi H, Baumann A, Bazin JE, Bizouarn P, Crozier S, Devalois B, Eon B, Fieux F, Frot C, Gisquet E, Guibet Lafaye C, Kentish-Barnes N, Muzard O, Nicolas-Robin A, Lopez MO, Roussin F, Puybasset L. [Euthanasia, assisted suicide and palliative care: a review by the Ethics Committee of the French Society of Anaesthesia and Intensive Care]. ACTA ACUST UNITED AC 2012; 31:694-703. [PMID: 22922010 DOI: 10.1016/j.annfar.2012.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 07/19/2012] [Indexed: 10/28/2022]
Abstract
CONTEXT Management of the end of life is a major social issue which was addressed in France by law, on April 22nd 2005. Nevertheless, a debate has emerged within French society about the legalization of euthanasia and/or assisted suicide (E/AS). This issue raises questions for doctors and most especially for anesthetists and intensive care physicians. OBJECTIVE To highlight, dispassionately and without dogmatism, key points taken from the published literature and the experience of countries which have legislated for E/AS. RESULTS The current French law addresses most of the end of life issues an intensive care physician might encounter. It is credited for imposing palliative care when therapies have become senseless and are withdrawn. However, this requirement for palliative care is generally applied too late in the course of a fatal illness. There is a great need for more education and stronger incentives for early action in this area. On the rare occasions when E/AS is requested, either by the patient or their loved-ones, it often results from a failure to consider that treatments have become senseless and conflict with patient's best interest. The implementation of E/AS cannot be reduced to a simple affirmation of the Principle of autonomy. Such procedures present genuine difficulties and the risk of drift. CONCLUSION We deliver a message of prudence and caution. Should we address painful end of life and moral suffering issues, by suppressing the subject, i.e. ending the patient's life, when comprehensive palliative care has not first been fully granted to all patients in need of it ?
Collapse
Affiliation(s)
- L Beydon
- Pôle d'anesthésie-réanimation, centre hospitalier universitaire d'Angers, 4, rue Larrey, 49033 Angers cedex 01, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
244
|
Palliative and end-of-life care in the global response to multidrug-resistant tuberculosis. THE LANCET. INFECTIOUS DISEASES 2012; 12:643-6. [DOI: 10.1016/s1473-3099(12)70084-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
245
|
Kumar P, Casarett D, Corcoran A, Desai K, Li Q, Chen J, Langer C, Mao JJ. Utilization of supportive and palliative care services among oncology outpatients at one academic cancer center: determinants of use and barriers to access. J Palliat Med 2012; 15:923-30. [PMID: 22731514 DOI: 10.1089/jpm.2011.0217] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
UNLABELLED Abstract Background: Cancer causes significant symptom burden and diminished quality of life. Despite the expansion of supportive and palliative care services (SPCS), little is known about rates of utilization and barriers to access to these services among oncology outpatients. METHODS We performed a cross-sectional survey in three outpatient medical oncology clinics. Patients with a diagnosis of breast, lung, or gastrointestinal (GI) cancer and a Karnofsky score of ≥60 were included. Patients reported their use of SPCS and any perceived barriers. Multivariable logistic regression was used to identify factors associated with SPCS use. RESULTS Among 313 participants, (50.5%) had not used SPCS since cancer diagnosis. The most common services used were nutrition (26.5%), psychiatric/psychological counseling (29.7%), and physical therapy (15.1%). Pain/palliative care and cancer rehabilitation consultations were used by 8.5% and 4.1% of participants, respectively. In multivariate analysis, graduate education was associated with greater SPCS use (adjusted odds ratio [AOR] 2.14, 95% confidence interval [CI] 1.08-4.26) compared with those with high school or less, whereas having lung cancer was associated with less SPCS use (AOR 0.48, 95% CI 0.24-0.96) when compared with those having breast cancer. The biggest reported barriers to using SPCS were a lack of awareness (22.4%) and lack of physician referral (23%). CONCLUSIONS Approximately half of these patients had not accessed SPCS since cancer diagnosis and cite lack of awareness and physician nonreferral as barriers. Further research is needed to understand patients' needs and beliefs regarding SPCS, and how to integrate SPCS into conventional treatments to improve cancer care.
Collapse
Affiliation(s)
- Pallavi Kumar
- Division of Geriatric and Palliative Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street / 2 Gates, Philadelphia, PA 19104, USA
| | | | | | | | | | | | | | | |
Collapse
|
246
|
Buone cure di fine vita in ospedale. Un obiettivo possibile e necessario. ITALIAN JOURNAL OF MEDICINE 2012. [DOI: 10.1016/j.itjm.2011.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
247
|
Dyar S, Lesperance M, Shannon R, Sloan J, Colon-Otero G. A nurse practitioner directed intervention improves the quality of life of patients with metastatic cancer: results of a randomized pilot study. J Palliat Med 2012; 15:890-5. [PMID: 22559906 DOI: 10.1089/jpm.2012.0014] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND There is a paucity of randomized studies evaluating the value of palliative interventions on a prospective basis in newly diagnosed oncology patients. We sought to prospectively evaluate quality of life (QoL) outcomes in advanced cancer patients who received discussion-based palliative care interventions from an advanced registered nurse practitioner (ARNP) integrated into the oncology team, and compare these outcomes with a control population. METHODS Patients with metastatic cancer were randomized to standard care or an ARNP-directed intervention that included discussions of the benefits of hospice, discussions on living wills and advanced directives (Five Wishes document) along with an assessment of QoL. Relevant endpoints included change from baseline QoL and improvement in hospice knowledge. RESULTS From November 13, 2008, through July 28, 2009, 26 patients were accrued at the Mayo Clinic in Jacksonville, Florida. The study closed early due to published data demonstrating the benefits of early palliative care interventions in the management of metastatic cancer patients. Statistically significant improvements from baseline were noted in emotional and mental QoL assessments in the intervention group that were not seen in the control group. Patients found it useful to have the living will and Five Wishes documents offered as part of the ARNP intervention. CONCLUSIONS An ARNP-directed intervention that explains the benefits of hospice and addresses advanced directives early in the course of metastatic cancer patients' treatment, is well received by the patients and their relatives and leads to measurable improvement in the patient's emotional and mental QoL.
Collapse
Affiliation(s)
- Stephen Dyar
- College of Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | | | | | | | | |
Collapse
|
248
|
New Patient-Centered Care Standards from the Commission on Cancer: Opportunities and Challenges. ACTA ACUST UNITED AC 2012; 10:107-11. [DOI: 10.1016/j.suponc.2011.12.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 12/15/2011] [Accepted: 12/20/2011] [Indexed: 11/18/2022]
|
249
|
Zafar SY, Currow DC, Cherny N, Strasser F, Fowler R, Abernethy AP. Consensus-based standards for best supportive care in clinical trials in advanced cancer. Lancet Oncol 2012; 13:e77-82. [PMID: 22300862 DOI: 10.1016/s1470-2045(11)70215-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Best supportive care is poorly defined in clinical trials, and a standard framework for delivery of such care is needed, using best available evidence and allowing replication of studies. We convened a panel of 36 experts to develop consensus statements via the Delphi method. The first round included open-ended questions; subsequent rounds sought to develop consensus-based standards. Consensus was assessed by use of a 5-point Likert agreement scale; more than 70% of panellists had to give a score of 5 to meet a-priori levels of consensus. The panel identified four key domains of best supportive care in clinical trials: multidisciplinary care; supportive care documentation; symptom assessment; and symptom management. Consensus was reached on 11 statements within these four domains. For example, 24 (96%) panellists recommended that the intervals between symptom assessments should be identical for control and experimental groups. Availability of resources was cited as a challenge to implementation of best supportive care standards.
Collapse
Affiliation(s)
- S Yousuf Zafar
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
| | | | | | | | | | | |
Collapse
|
250
|
Al-Zahrani AS, El-Kashif AT, Haggag RM, Alsirafy SA. Pattern of cancer deaths in a saudi tertiary care hospital. Am J Hosp Palliat Care 2012; 30:21-4. [PMID: 22378940 DOI: 10.1177/1049909112437574] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The medical records of deceased patients were reviewed to describe the pattern of cancer deaths in a newly established Saudi tertiary care hospital. During eleven months, 87 patients died of cancer. The majority (80 patients, 92%) died of incurable cancer; among which 53% did not receive any systemic anti-cancer therapy (SAT) and 43% received SAT with palliative intent. Younger age (< 65 years), relatively chemosensitive tumours and initial presentation in a potentially curable stage were associated with higher prevalence of palliative SAT administration (p = 0.009, 0.019 and 0.001, respectively). The last palliative SAT was administered during the last two months of life in 66% and during the last two weeks in 14%. During the last admission, 54% of patients were admitted through emergency room, 50% stayed >14 days and 14% died in intensive care unit or emergency room. The results demonstrate that palliative care is a realistic treatment for the majority of patients in our setting and that a significant proportion of these patients receive aggressive care at the end-of-life. There is a need to establish an integrative palliative care program to improve the quality-of-life of dying cancer patients in our region and to minimize the aggressiveness of end-of-life care.
Collapse
|