Setting up a palliative care clinic within a radiotherapy department: a model for developing countries

Palliative Care Delivery Systems and Integration With Palliative Care Teams

Radiotherapy (RT) plays a critical role in the palliation of symptoms in patients with advanced or metastatic cancer. To address the growing need for these services, multiple dedicated palliative RT programs have been established. This article serves to highlight the novel ways in which palliative RT delivery systems support patients with advanced cancer. Through early integration of multidisciplinary palliative supportive services, rapid access programs facilitate best practices for oncologic patients at the end of life.

What Promotes Medical Overuse: Perspective on Evolutionary Game between Administration and Medical Institutions

Medical overuse is the leading cause of high expenditure among healthcare systems worldwide, with the degree varying from region to region. There is increasing evidence to indicate that in China, National Healthcare Security Administration (NHSA) supervision plays the most crucial role in decreasing medical overuse. For medical overuse, traditional studies focus on empirical researches and qualitative analysis, most of which ignore how the two important participants, i.e., medical institutions and NHSA, affect the strategy of each other. To reduce the losses incurred by insufficient supervision, this study starts from bounded rationality, builds an evolutionary game model to study the relations between the NHSA and medical institutions, and reveals the dynamic evolution process of the supervision of NHSA and overuse of medical institutions. Through stable evolutionary strategy analysis, numerical simulation results, and sensitive experiments under diverse scenarios, we found that when profit gap of medical overuse is high or low, medical institution will adopt fixed strategy, which is medical overuse or appropriate medical use. Only when the profit gap is at a medium level will NHSA's choice affects medical institutions' strategy. Furthermore, NHSA's strategy is affected by the profit gap between medical use and supervision cost. Our work enriches the understanding of supervision for medical overuse and provides theoretical support for the NHSA to make decisions to reach an ideal condition, i.e., to supervise without exertion.

"Find Out What They Lack, Try to Provide": A Qualitative Investigation of Palliative Care Services Adapted to Local Need in a Low-Resource Setting

Background: People in low- and middle-income countries with serious health problems rarely have access to palliative care. Promising models of palliative care delivery have emerged in India despite widespread poverty and poor health care infrastructure. Objective: To explore structural and philosophical aspects of palliative care delivery in a low-resource setting. Design: One author spent six months as a participant observer at Pallium India (PI), a nongovernmental organization recognized for leadership in palliative care delivery in Kerala, India. We collected administrative data, conducted semistructured interviews with key stakeholders, and observed clinical encounters and other organization-led events. Results: We performed 73 interviews with patients, families, clinicians, staff, and volunteers, and observed 180 patient encounters. The majority of palliative care patients did not have cancer. Many had chronic diseases that were not immediately life threatening. Services addressed a broad range of patients' medical, psychological, social, and/or financial needs. PI's care delivery maximizes accessibility. Conclusions: PI employs an expansive definition of palliative care and adapts services to respond to patients' diverse needs. This accessible, people-centered care is necessary in low-resource settings to alleviate multifaceted suffering caused by gaps in the health care system, poor social support, and poverty.

An evaluation of an advanced practice role in palliative radiation therapy

Introduction

The purpose of the study was to evaluate the palliative advanced practice radiation therapy (APRT) role with respect to the impact on waiting times for patients from referral to radiation treatment delivery, the ability of the APRT to define palliative radiation therapy fields and patient satisfaction. The evaluation of the impact of the APRT role and referral pathway on patient waiting times has been previously published.

Methods

Patients were allocated to two different pathways; APRT and standard. Patients in the APRT pathway had their radiotherapy treatment managed by the APRT including defining their palliative fields blinded to the radiation oncologist (RO).

Results

Of the 150 palliative patients, 94 had their radiation therapy managed by the APRT and 56 were managed through the standard pathway. 82/92 APRT defined fields were accepted by the RO.

Conclusions

Inter‐observer variability between the APRT and the RO in defining palliative radiation therapy fields is similar to that reported in the literature between clinicians. With previously published reduced wait times from referral to treatment for palliative patients, the establishment of the APRT role is justified.

A Systematic Review of Palliative Care Intervention Outcomes and Outcome Measures in Low-Resource Countries

CONTEXT

To meet the growing need for palliative care in low-resource countries, palliative care programs should be evidence based and contextually appropriate. This study was conducted to synthesize the current evidence to guide future programmatic and research efforts.

OBJECTIVES

This systematic review evaluated palliative care outcome measures, outcomes, and interventions in low-resource countries.

METHODS

After title searches, abstracts and full-text articles were screened for inclusion. Data were extracted to report on intervention models, outcome measures used, and intervention outcomes.

RESULTS

Eighteen papers were reviewed, reporting on interventions conducted across nine low-resource countries. These interventions evaluated home-based palliative care models; a community-managed model; palliative care integrated with hospitals, hospices, or HIV clinics; and models focused on patients' self-management. Three studies were randomized controlled trials. Other studies used nonrandomized trials, cohort studies, mixed methods, pre-post test evaluation, cost-accounting evaluation, and cross-sectional surveys. Thirteen studies measured physical outcomes, 10 using multidimensional instruments. Nine studies measured psychological outcomes, eight using multidimensional instruments. Nine studies measured social outcomes, seven using multidimensional instruments. Nine studies measured outcomes across multiple domains. Across outcomes evaluated, results were reported in the direction of benefit associated with palliative care interventions.

CONCLUSION

Many palliative care intervention models exist to serve patients in low-resource countries. Yet, limited high-quality evidence from low-resource countries is available to document intervention outcomes. Rigorous experimental studies and greater measurement of multidimensional aspects of palliative care are needed to advance the science of palliative care in low-resource settings.

Evidence for overuse of medical services around the world

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.

The Business of Palliative Medicine—Part 5: Service Utilization in a Comprehensive Integrated Program

The aim of palliative medicine is to provide multidisciplinary comprehensive care in advanced illness. Patient and family utilization of various product service lines offered by the Harry R Horvitz Center for Palliative Medicine at the Cleveland Clinic Foundation was studied. Newly referred patients were followed up prospectively until 85% had either died or been lost to follow-up. Demographic, clinical, and referral data were recorded; subsequent product service line utilization was updated daily. The total study period was 171 days, and 238 patients entered. Acute care inpatient unit, outpatient clinic visits, and 24-hour phone contacts were the most frequently used product service lines. Patients had a median of 3 contacts (range, 1 to 27) with individual service lines. Multiple palliative medicine product service lines were utilized often, with repeated use of the individual service lines. A comprehensive integrated palliative medicine program is necessary to fully meet the complex needs of those with advanced disease.

Initial Experience of Head and Neck Cancer Patients Treated in an Oncologist Led Palliative Cancer Care Clinic at a Tertiary Cancer Care Center in Uttar Pradesh: Is the Initiative of a Full-fledged Palliative Care for Cancer Patients Justified

Introduction:

Poor socioeconomic status and illiteracy attribute to the advanced presentation of head and neck cancer (HNC) patients in India and are candidates for palliation in our setup. We set up a palliative cancer care clinic (PCCC), and an audit of initial 153 HNC patients is presented.

Aims and Objectives:

To assess the impact of palliative cancer care services.

Methodology:

Data of advanced HNC patients suited for palliation were collected to document demography, symptomatology, cancer treatment, and supportive care.

Results:

One hundred and fifty-three patients were seen during January 2013 to March 2015 in the PCCC. Seventy-two (47%) referral cases were due to disease progression and 81 (53%) due to de novo advanced cases. Median follow-up for this group was 5.3 months. Ninety (59%) cases needed some degree of assistance for their normal activities. Sixty-seven (44%) patients belonged to poor socioeconomic status and 65 (43%) were educated up to equivalent of high school. One hundred and thirty-five (88%) patients had an adequate family support. Pain was the most common presenting symptom in 134 (87%) cases with adequate relief in 112 (84%) patients with another 13 (09%) could not be assessed. Overall median duration of symptoms was 6 months. Cancer-directed therapy was used in 143 (93%) patients. Near the end of life in 47 (73%) out of 63 documented cases, caregivers were psychologically prepared for the inevitable.

Conclusion:

The role of palliative care team in alleviating physical, psychosocial, and emotional issues of patient and family members was significant. PCCC seems to be a feasible working model in our setup.

Rapid access palliative radiation therapy programs: an efficient model of care

Palliating symptoms of advanced and metastatic cancers are one of the most common indications for radiation therapy (RT), and the demand for palliative RT is increasing. Dedicated rapid access palliative RT programs improve access to care, and can deliver RT in a more efficient and evidence-based manner than standard RT programs. In this narrative review, we discuss the role of palliative RT in comprehensive cancer care, and challenges that have faced patients trying to access it. We describe how rapid access programs developed to address these challenges and provide an overview of dedicated programs worldwide. Finally, we show how these programs can serve as models for multidisciplinary care and education, and sources of exciting research opportunities in clinical care and advanced technologies.

Retinoblastoma

Retinoblastoma is a rare cancer of the infant retina that is diagnosed in approximately 8,000 children each year worldwide. It forms when both retinoblastoma gene (RB1) alleles are mutated in a susceptible retinal cell, probably a cone photoreceptor precursor. Loss of the tumour-suppressive functions of the retinoblastoma protein (pRB) leads to uncontrolled cell division and recurrent genomic changes during tumour progression. Although pRB is expressed in almost all tissues, cone precursors have biochemical and molecular features that may sensitize them to RB1 loss and enable tumorigenesis. Patient survival is >95% in high-income countries but <30% globally. However, outcomes are improving owing to increased disease awareness for earlier diagnosis, application of new guidelines and sharing of expertise. Intra-arterial and intravitreal chemotherapy have emerged as promising methods to salvage eyes that with conventional treatment might have been lost. Ongoing international collaborations will replace the multiple different classifications of eye involvement with standardized definitions to consistently assess the eligibility, efficacy and safety of treatment options. Life-long follow-up is warranted, as survivors of heritable retinoblastoma are at risk for developing second cancers. Defining the molecular consequences of RB1 loss in diverse tissues may open new avenues for treatment and prevention of retinoblastoma, as well as second cancers, in patients with germline RB1 mutations.

The need of pediatric palliative care education among pediatric postgraduates in South India

OBJECTIVES

To assess the status of Pediatric Palliative care education among the pediatric postgraduates in South India and reinforce the need to introduce a targeted curriculum to improve their skills and confidence levels in handling terminally ill children.

METHODS

The study was conducted in a 2 d workshop attended by 180 pediatric postgraduates from South India. An 18 point questionnaire was given to the participants and the questions were to test their clinical knowledge and confidence levels in treating terminally ill children. SPSS 18.V software was used for statistical analysis.

RESULTS

Eighty eight percent of the postgraduates had never received any training in any aspect of palliative care. 77.3 % felt uncomfortable in initiating a discussion about palliative care with the family members. 60.7 % were not comfortable with the care of the dying patient. 87.3 % strongly supported that a formal training in palliative care would improve their competence in this field.

CONCLUSIONS

There is a huge lacunae in the delivery of palliative care services and hence an urgent need to inculcate targeted curriculum to provide focused skills and training for the pediatric postgraduates.

Palliative care in India: current progress and future needs

Despite its limited coverage, palliative care has been present in India for about 20 years. Obstacles in the growth of palliative care in India are too many and not only include factors like population density, poverty, geographical diversity, restrictive policies regarding opioid prescription, workforce development at base level, but also limited national palliative care policy and lack of institutional interest in palliative care. Nonetheless we have reasons to be proud in that we have overcome several hurdles and last two decades have seen palpable changes in the mindset of health care providers and policy makers with respect to need of palliative care in India. Systematic and continuous education for medical staff is mandatory, and a major break-through for achieving this purpose would be to increase the number of courses and faculties in palliative medicine at most universities.

Learning from each other: cross-cultural insights on palliative care in Indian and Australian regions

This article presents the findings of a cross-cultural research project that explored similarities and differences between palliative care service provision in Kerala, India and South-East Queensland, Australia, to inform a process of mutual learning for service development. Three major points of difference that can inform this process of mutual learning were identified: 1) an understanding of the significance of honesty in information-giving to the patient, 2) recognition of the importance of palliative care specialists providing education to mainstream health professionals, and 3) appreciation of the need for palliative care to be cognizant of the socio-economic impact of dying-especially for families experiencing poverty-by embracing strategies for financial and material support. The findings highlight the effectiveness of a cross-cultural collaboration between health professionals and researchers in South-East Queensland, Australia and Kerala, India.

Hospice and palliative care development in India: a multimethod review of services and experiences

Palliative care has been developing in India since the mid-1980s, but there is a dearth of evidence about service provision on which to base national policy and practice. The aim of this study was to assess the current state of palliative care in India, mapping the existence of services state by state, and documenting the perspectives and experiences of those involved. A multimethod review was used, which included synthesis of evidence from published and grey literature, ethnographic field visits, qualitative interviews with 87 individuals from 12 states, and collation of existing public health data. The review identified 138 hospice and palliative care services in 16 states and union territories. These are mostly concentrated in large cities, with the exception of Kerala, where they are much more widespread. Nongovernmental organizations, public and private hospitals, and hospices are the predominant sources of provision. We were unable to identify palliative care services in 19 states/union territories. Development of services is uneven, with greater provision evident in the south than the north, but for the majority of states, coverage is poor. Barriers to the development of palliative care include: poverty, population density, geography, opioid availability, workforce development, and limited national palliative care policy. Successful models exist for the development of affordable, sustainable community-based palliative care services. These have arisen from adapting Western models of hospice and palliative care for implementation in the Indian cultural context. Further work is required to ensure that the growing interest in hospice and palliative care in India is used to increase the momentum of progress.