Requests from professional care providers for consultation with palliative care consultation teams

Training general practitioners in early identification and anticipatory palliative care planning: a randomized controlled trial

BACKGROUND

Most patients with advanced cancer, debilitating COPD or chronic heart failure (CHF) live at home. General practitioners (GPs) asked for guidance in how to recognize patients in need of palliative care in a timely way and to structure anticipatory care. For that reason, we developed a training for GPs in identifying patients in need of palliative care and in structuring anticipatory palliative care planning and studied its effect on out-of-hours contacts, contacts with their own GP, hospitalizations and place of death.

METHODS

We performed a cluster randomised controlled trial. GPs in the intervention group were trained in identifying patients in need of palliative care and anticipatory care planning. Next, for each identified patient, they were offered a coaching session with a specialist in palliative care to fine-tune a structured care plan. The GPs in the control group did not receive training or coaching, and were asked to provide care as usual. After one year, characteristics of patients deceased of cancer, COPD or CHF in both study groups were compared with mixed effects models for out-of-hours contacts (primary outcome), contacts with their own GP, place of death and hospitalizations in the last months of their life (secondary outcomes). As a post-hoc analysis, of identified patients (of the intervention GPs) these figures were compared to all other deceased patients, who had not been identified as in need of palliative care.

RESULTS

We did not find any differences between the intervention and control group. Yet, only half of the trained GPs (28) identified patients (52), which was only 24% of the deceased patients. Those identified patients had significantly more contacts with their own GP (B 4.5218; p <0.0006), were less often hospitalized (OR 0.485; p 0.0437) more often died at home (OR 2.126; p 0.0572) and less often died in the hospital (OR 0.380; p 0.0449).

CONCLUSIONS

Although we did not find differences between the intervention and control group, we found in a post-hoc analysis that those patients that had been identified as in need of palliative care had more contacts with their GP, less hospitalizations, and more often died at home. We recommend future controlled studies that try to further increase identification of patients eligible for anticipatory palliative care. The Netherlands National Trial Register: NTR2815 date 07-04-2010.

Essential knowledge for family caregivers: a qualitative study

BACKGROUND

Family caregivers are the backbone of the social care delivery system. With cancer and other life-limiting diseases on the rise, the need for well-informed informal/family caregivers has never been greater.

AIM

To uncover the information that palliative care teams routinely provide to family caregivers.

DESIGN

The methodology used was the nominal group technique, a type of focus group.

PARTICIPANTS

A total of 17 community palliative care health professionals participated in one of three focus groups.

RESULTS

Three themes emerged as dominant priorities for the education of family caregivers: caring for oneself physically, emotionally, and spiritually; learning practical skills; and knowing what to expect and plan for as the family member's health declines.

CONCLUSIONS

The participants encourage caregivers to meet their own needs as well as care for family members. They help to empower family caregivers by encouraging them to take time for themselves, providing practical information for individual situations, and educating them on the signs and symptoms of approaching death. Successful terminal home care is possible through family caregiver support and empowerment.

PAL-MED CONNECT ®: a telephone consultation hotline for palliative medicine questions

BACKGROUND

Community physicians are often ill-prepared for the management of complex symptoms. With a shortage of board certified physicians in palliative medicine to assist, the result is a lack of access to critical pain and symptom management expertise to care for seriously ill Californians. We report on a palliative medicine telephone hotline available to health care professionals.

METHODS

San Diego Hospice and The Institute for Palliative Medicine received a grant to provide a telephone hotline for health care professionals to assist in answering clinical questions relating to palliative care. An extensive marketing campaign was initiated to publicize the service. Information from the calls was collected over a 2.5-year period. The data included referral source, geographic area, diagnosis, and reason for call. Satisfaction surveys were sent following each call.

RESULTS

During the first 2.5 years of operation 498 calls were recorded. Although marketing was directed within the state of California, the majority of calls originated outside the state after the first year (66%). Approximately 43% of calls came from physicians, followed by 22% from registered nurses, 15% from nurse practitioners, and 6% from pharmacists. Nearly half of the calls were received from repeat callers. The most frequent topics for callers were related to pain and symptom management (29%), followed by hospice care (21%), medication dosing, and general palliative care (14% each). Ninety-five percent of the callers completed the satisfaction survey with 89% likely to use the service again.

CONCLUSIONS

The hotline proved to be a valuable resource for health care providers caring for patients requiring palliative care as evidenced by the steady increase in the number of calls over the initial 2.5 years of operation. Future research on how the information directly impacted patient care might generate data to support the continuation of this service via partnerships with other organizations.

Development of a standard for hospital-based palliative care consultation teams using a modified Delphi method

Although palliative care consultation teams are rapidly being disseminated throughout Japan as a result of government policy, the role of these teams has not been standardized. The aim of this study was to develop a hospital-based palliative care consultation team standard. We adopted a modified Delphi method to develop a standard. Twenty-seven multiprofessional panelists were selected according to two criteria: adequate experience as part of a palliative care consultation team and representative of 16 palliative care-related organizations. Panelists rated the appropriateness of 33 statements in a provisional standard, which was generated by the authors, using a nine-point Likert-type scale in a first-round survey. We set two criteria for agreement: the median value was 8 or more, and the difference between the minimum and maximum was 4 or less. There were 15 disagreements in the first-round survey. Based on discussions through e-mails and a panel meeting, these 15 statements were dealt with as follows: one was rejected, one was combined with another statement, three were unmodified, and 10 underwent minor revisions. Moreover, two statements that generated agreement were divided into two statements each. Consequently, the number of statements was 37. In a second-round survey, three statements engendered disagreement and were modified. At the end of the process, there were 37 statements in four areas: "philosophy and policy," "structure for care provision," "contents of activities," and "quality assurance and care improvements." This standard may be useful as a clinical activity guide as well as a method to evaluate palliative care consultation teams.

Providing care and sharing expertise: Reflections of nurse-specialists in palliative home care

Objective:

This study explored the experiences, perspectives, and reflections of five nurse-specialists in palliative home care, whose dual role includes caring for patients in their daily practice as well as sharing their knowledge, skills, expertise, and experiences with other home care nurses in the community.

Methods:

A qualitative research design, incorporating face-to-face semistructured interviews, was used. Interviews were based on open-ended questions such as: “What is your experience in providing palliative home care to patients and their families? How do you feel about sharing your expertise and experiences with home care nurses?” Data were content analyzed using the constant comparative method.

Results:

Three major themes and a number of subthemes emerged: (1) acknowledging one's own limitations and humanness: (a) calling for backup, (b) learning as we go along, (c) coping with emotional demands, and (d) interacting with family members; (2) building a collaborative partnership: (a) working collaboratively, (b) sharing information, (c) guiding home care nurses, and (d) being nonjudgmental; and (3) teamwork and implementing palliative home care teams.

Significance of results:

Nurse-specialists play a key role in palliative home care as both carers and as resources of expert knowledge for other home care nurses caring for palliative patients. As the population ages, the health care system will be faced with increasing requests for high-quality palliative home care. The results of this study demonstrate that, from the perspective of the nurse-specialists of NOVA-Montréal (a nonprofit social and health service organization), nurse-specialists can work collaboratively with home care nurses to improve patients' quality of care and their quality of life. Moreover, patients and their families would benefit from the more widespread establishment of palliative care teams within community health organizations.

Presence, communication and treatment of fatigue and pain complaints in incurable cancer patients

OBJECTIVE

This study describes the experiences of fatigue and pain in incurable cancer patients and the treatment they receive.

METHODS

Patients were recruited via medical specialists from hospitals in the South and Southwest of the Netherlands. Hundred and twenty-five incurable cancer patients filled out a written questionnaire and were also interviewed at home.

RESULTS

Ninety percent reported to suffer from fatigue and 48% had pain. Forty-five percent had discussed fatigue with a healthcare professional and 55% had discussed pain. Fifteen percent reported to receive medical treatment for their fatigue and 29% received pain treatment. Treatment for fatigue and pain treatment had been recently adjusted in 4% of the patients with fatigue complaints and 21% of the patients with pain complaints.

CONCLUSION

Although fatigue is a more common problem than pain in patients with incurable cancer, less attention in the care is paid to fatigue and its treatment than to pain.

PRACTICE IMPLICATIONS

Fatigue deserves more attention in the care policy for incurable cancer patients and more research should be focused on interventions to address fatigue in this group of cancer patients.

Obstacles to the delivery of primary palliative care as perceived by GPs

INTRODUCTION

In order to facilitate GPs in their work and increase the possibilities for patients to remain at home, it is important to identify the obstacles which hinder the delivery of primary palliative care. From previous research we learned about some of the problems experienced by GPs. In this survey we aimed to identify the prevalence of such problems in providing palliative care and its determinants.

METHODS

The prevalence of obstacles and its determinants were identified by a questionnaire to 320 GPs in three regions of the Netherlands. Obstacles were grouped as follows: communication, organisation & co-ordination of care, knowledge & expertise, integrated care, time for relatives. The potential determinants were GP characteristics and expertise development activities.

RESULTS

The response rate was 62.3%. GPs experienced considerable obstacles in all aspects of palliative care. The most prevalent were: problems with bureaucratic procedures (83.9%), the time necessary to arrange home care technology (61.1%) and the difficulties accompanied with the wish or necessity to obtain extra care (56.3%). In general, more years of GP experience and the participation in (multidisciplinary) case discussions were associated with less perceived obstacles.

DISCUSSION

Based on the results of our survey policymakers and practitioners can plan and set priorities in handling the obstacles. There is a high necessity of firstly overcoming the barriers within organisation and coordination of care. Furthermore, our study can help in choosing the (additional) expertise needed in the future and in the realisation of the preferred expertise advancement activities.

Consultation in palliative care: The relevance of clarification of problems

This study aims to determine the extent and nature of problems in palliative care that are newly identified in the consultation process and the factors influencing their identification. The consultation process includes clarification of problems mentioned by professionals requesting advice. Data are derived from the standard registration forms of Palliative Care Consultation teams. Multilevel logistic regression analysis was carried out with newly identified problem as dependent variable. Fifty seven percent of problems (n=7854) were newly identified. Most newly identified problems were related to physical and pharmacological problems. If psychosocial/spiritual problems were identified, this occurred in most cases through clarification (70%). Newly identified problems were more likely to be identified in the domain of spiritual and psychosocial problems, in bedside consultations, in requests from clinical physicians, and for patients accommodated in a hospice or hospital. Explicit clarification of problems facilitates the identification and addressing of a more comprehensive and specific scope of problems.

Telephone consultation in palliative care for cancer patients: 5 years of experience in The Netherlands

GOALS OF WORK

To analyze cancer patient-related consultations of a telephone helpdesk (TH) for palliative care over a period of 5 years in the region of Utrecht, The Netherlands.

MATERIALS AND METHODS

A descriptive analysis was performed of consultations over a period of 5 years (2001-2006). The discipline and location of requesting professionals, patient characteristics, reasons for calling, symptoms, palliative care problems and needs for support were registered.

MAIN RESULTS

A total of 1,794 consultations were analyzed. There was an increasing number of consultations during the study period. Of the patients, 51% were male and their median age was 65 years (range 0-104). Eighty-four percent were treated at home by their general practitioner. Two thirds of the patients had a life expectancy <4 weeks. Most questions referred to pain (49%), delirium (20%), nausea and vomiting (16%) and dyspnea (12%). The median number of symptoms was 1 (0-6). Of the questions, 54% were related to pharmacological problems, 19% to psychological problems and 21% to the organization of care. Of the requesting professionals, 17% asked for support for themselves. Of the consultations, 14% were related to end-of-life issues: palliative sedation (11%) and euthanasia (3%).

CONCLUSION

After more than 5 years, the 24-h telephone consultation service fulfills a need for general practitioners dealing with daily dilemmas in palliative care treatment for cancer patients at home during the last period of their life.

Spiritual issues in palliative care consultations in the Netherlands

INTRODUCTION

In the Netherlands, healthcare professionals are able to consult Palliative Care Consultation (PCC) teams about individual patients, for information, support and advice. This study aims to understand which spiritual issues are discussed in these consultations and to determine which factors influence whether they are raised or not.

METHODS

The national register of the consultations of the PCC teams was analysed for a two-year period.

RESULTS

Spiritual issues played a role in 8.4% of palliative care consultations, of which 4.1% were by phone and 18.3% were bedside consultations. Often spiritual issues were raised by the consultant during the exploration of the request from the caregiver; the discipline of the consultant rather than the discipline of the requesting professional or the patient characteristics determined whether or not such issues were raised. The main support given by the consultant was in coaching the professional caregiver on how to address these issues.

DISCUSSION

This study demonstrates the important role of PCC team consultants in exploring and identifying the spiritual needs of patients about whom they are consulted. Although continued education in spiritual care for palliative care professionals is essential, PCC team consultants will play an important role in drawing the attention of healthcare professionals to the need to recognize and address the spiritual needs of their patients.