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Galiano A, Feltrin A, Pambuku A, Lo Mauro L, De Toni C, Murgioni S, Soldà C, Maruzzo M, Bergamo F, Brunello A, Zagonel V. What do cancer patients experience of the simultaneous care clinic? Results of a cross-sectional study on patient care satisfaction. Cancer Med 2024; 13:e7000. [PMID: 38400662 PMCID: PMC10891442 DOI: 10.1002/cam4.7000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/28/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Veneto Institute of Oncology has activated a simultaneous care outpatient clinic (SCOC) in which cancer patients with advanced-stage cancer are evaluated by oncologist and palliative care specialists. This cross-sectional study investigated patients' perceptions of the quality of this service. MATERIALS AND METHODS An ad-hoc self-administered questionnaire, developed by SCOC team, was used to assess the satisfaction of patients admitted at SCOC consultation. The questionnaire, in addition to the socio-demographic questions, contains eight questions with the Likert scale: time dedicated, feel listened to, feel understood, feel free to speak openly and to express doubts and concerns, feeling about information and indication received, level of empathy of health care and quality of the relationship, level of professional/quality of performance and utility of consultation, and one open-ended question. The questionnaire has been proposed to all 174 consecutively admitted patients at SCOC. RESULTS One hundred and sixty-two patients filled in the questionnaire: 66.7% were male, median age was 71 years, 88.3% had metastatic disease. The time dedicated to SCOC consultation was judged more than adequate (55%) or adequate (35%) by 90% of subjects. Patients completely satisfied about being listened to were 92.5%, with 80.9% being completely satisfied with understanding of their issues and 92% with the freedom to speak and express doubts. Usefulness of the SCOC was rated as excellent by 40% and good by 54.4% of patients. No statistically significant differences were observed in the responses to the questions by gender, age (< or ≥70 years old) and type of tumor. CONCLUSION Our study shows high levels of satisfactions after SCOC consultation in advanced cancer subjects. Patients' feedback confirmed that SCOC model was effective in helping them during their treatment journey and decision at the end of life. This study encouraged us to enhance our practice of SCOC consultation. IMPLICATIONS FOR PRACTICE A joint evaluation of patients living with cancer by oncologist and palliative care team (SCOC-embedded model), has shown to enhance patients' experience/satisfaction with care-such as listening, understanding, receiving information, symptom control, and decision about future, independently of age, gender, and kind of tumor.
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Affiliation(s)
- Antonella Galiano
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | | | - Ardi Pambuku
- Pain Therapy and Palliative Care UnitVeneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Leda Lo Mauro
- Clinical Nutrition Unit, Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Chiara De Toni
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Sabina Murgioni
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Caterina Soldà
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Marco Maruzzo
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Francesca Bergamo
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Antonella Brunello
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Vittorina Zagonel
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
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Birkner DR, Schettle M, Feuz M, Blum D, Hertler C. Outpatient Palliative Care Service Involvement: A Five-Year Experience from a Tertiary Hospital in Switzerland. Palliat Med Rep 2024; 5:10-19. [PMID: 38249832 PMCID: PMC10797309 DOI: 10.1089/pmr.2023.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/23/2024] Open
Abstract
Background The value of early integration of palliative care has been demonstrated increasingly for the past years in both oncological and nononcological diseases. Outpatient palliative care services might represent a feasible approach to implement supportive care in early disease. In this study, we aimed at evaluating which patients use and benefit from outpatient palliative care services, which symptoms are addressed most, and which support services are installed in this early phase of disease. Methods We retrospectively analyzed the entire patient collective of a recently developed palliative care outpatient clinic within the leading university hospital in Switzerland for a period of five years. Sociodemographics, symptoms, and information on disease as well as patient-reported outcomes were retrieved from the electronic patient files. Demographic and clinical data were analyzed by descriptive statistics between groups and survival was analyzed by means of Kaplan-Meier estimates and log-rank test. Results We report on 642 consultations of 363 patients between 2016 and 2020. Patients had a mean of 1.8 visits (range 1-10), with n = 340 patients (93.7%) of patients suffering from an oncological disease. Overall symptom load was high, with n = 401 (73.7%) of patient-reported outcomes reporting two or more symptoms. Distress levels of 5 or higher were reported in n = 78 (30.4%) of available patient-reported outcomes. Independent of the origin of primary disease and the length of the disease trajectory, patients were referred to the palliative care service in median only four months before death. Conclusion We identify high symptom load and distress in the outpatient palliative patient population. Patients benefitted from supportive medication, improvement of ambulatory support systems and advance care planning, and more than one-third of patients remained in follow-up, indicating a good acceptance of the service. Overcoming the overall late referral could, however, further increase the quality of life at earlier stages of disease.
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Affiliation(s)
| | - Markus Schettle
- Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
| | - Markus Feuz
- Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
| | - David Blum
- University of Zurich, Zurich, Switzerland
- Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
| | - Caroline Hertler
- University of Zurich, Zurich, Switzerland
- Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
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Chelazzi C, Ripamonti CI. How early should be "Early Integrated Palliative Care"? Support Care Cancer 2023; 32:41. [PMID: 38110598 PMCID: PMC10728221 DOI: 10.1007/s00520-023-08213-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/28/2023] [Indexed: 12/20/2023]
Abstract
Palliative care, with its focus on comprehensive patient assessment encompassing physical, social, emotional, and spiritual pain, plays a crucial role in modern medicine. Despite its significance, integration with oncology and other healthcare specialties often occurs late in the disease trajectory. Strategies to bridge this gap include considering a "rebranding" of palliative care to "supportive care." Early initiation of palliative care, although challenging to define precisely, aims to improve the quality of life for patients and their families. Studies show some benefits, but the evidence remains limited. An embedded model that encourages interdisciplinary collaboration between oncologists and palliative care practitioners has shown promise. However, it raises questions about training and availability of palliative care specialists. A broader approach involves integrating palliative care principles into medical and nursing education to ensure early recognition of patient needs and empathetic communication. Regular monitoring of patients' physical and non-physical needs, along with appropriate interventions, can alleviate suffering and improve patient outcomes. Ultimately, the integration of palliative care into oncology and other disciplines focuses on addressing the individual's needs and understanding their unique experience of suffering.
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Affiliation(s)
- Cosimo Chelazzi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Università degli Studi di Brescia, Brescia, Italy.
| | - Carla Ida Ripamonti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Università degli Studi di Brescia, Brescia, Italy
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Agne JL, Bertino EM, Gast K, Grogan MM, Janse S, Benedict J, Presley CJ. Improving Access to Early Palliative Care Delivery for Patients With an Advanced Thoracic Malignancy Through an Embedded Oncopalliative Clinic Model. JCO Oncol Pract 2023; 19:777-785. [PMID: 37279410 DOI: 10.1200/op.22.00454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 04/10/2023] [Accepted: 05/03/2023] [Indexed: 06/08/2023] Open
Abstract
PURPOSE Early integration of palliative care (PC) with standard oncology care is driving the development of innovative PC delivery models. METHODS This was a single-institution retrospective study of outpatient PC before and after the opening of an embedded thoracic oncology-palliative clinic at The Ohio State University. Patients included in the preintervention (October 2017-July 2018) and postintervention (October 2018-July 2019) cohorts had a diagnosis of any non-small-cell lung cancer (stages I-IV) or small-cell lung cancer (limited or extensive stage) and were newly established in the thoracic medical oncology clinic during the study time periods. All patients in the preintervention cohort had access to outpatient PC through a freestanding clinic, while the postintervention cohort had access to both freestanding and embedded clinics. Using time-to-event analyses, we evaluated differences in time intervals from first medical oncology visit to PC referral and first PC visit between cohorts. RESULTS The majority of patients in both cohorts had metastatic disease at diagnosis. In the postintervention cohort, 20.9% of patients were referred to outpatient PC compared with 9.2% in the preintervention cohort (P < .01). PC referrals for patients outside of Franklin and adjacent counties increased from 4.0% to 14.2% after opening the embedded clinic (P < .01). Completion percentages of PC referrals increased from 57.6% to 76.0% in the preintervention versus postintervention cohorts (P = .048). Median time from palliative referral order to first PC visit decreased from 29 to 20 days (P = .047). Similarly, median time from the first oncology visit to PC referral completion decreased from 103 to 41 days (P = .08). CONCLUSION Implementation of an embedded PC model was associated with increased access to early PC among patients with thoracic malignancies.
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Affiliation(s)
- Julia L Agne
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Erin M Bertino
- Division of Medical Oncology, The Ohio State University James Comprehensive Cancer Center, Columbus, OH
| | - Kelly Gast
- Division of Medical Oncology, The Ohio State University James Comprehensive Cancer Center, Columbus, OH
| | - Madison M Grogan
- Division of Medical Oncology, The Ohio State University James Comprehensive Cancer Center, Columbus, OH
| | - Sarah Janse
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jason Benedict
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Carolyn J Presley
- Division of Medical Oncology, The Ohio State University James Comprehensive Cancer Center, Columbus, OH
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Mohammed S, Swami N, Pope A, Rodin G, Zimmermann C. Strategies Used by Outpatient Oncology Nurses to Introduce Early Palliative Care: A Qualitative Study. Cancer Nurs 2023:00002820-990000000-00153. [PMID: 37406225 DOI: 10.1097/ncc.0000000000001258] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
BACKGROUND Although early palliative care is linked to improved health-related quality of life, satisfaction with care, and symptom management, the clinical strategies that nurses use to actively initiate this care are unknown. OBJECTIVES The aims of this study were to conceptualize the clinical strategies that outpatient oncology nurses use to introduce early palliative care and to determine how these strategies align with the framework of practice. METHODS A constructivist-informed grounded theory study was conducted in a tertiary cancer care center in Toronto, Canada. Twenty nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) from multiple outpatient oncology clinics (ie, breast, pancreatic, hematology) completed semistructured interviews. Analysis occurred concurrently with data collection and used constant comparison until theoretical saturation was reached. RESULTS The overarching core category, pulling it all together, outlines the strategies used by oncology nurses to support timely palliative care referral, drawing on the coordinating, collaborating, relational, and advocacy dimensions of practice. The core category incorporated 3 subcategories: (1) catalyzing and facilitating synergy among disciplines and settings, (2) promoting and considering palliative care within patients' personal narratives, and (3) widening the focus from disease-focused treatment to living well with cancer. CONCLUSION Outpatient oncology nurses enact unique clinical strategies, which are aligned with the nursing framework and reflected multiple dimensions of practice, to introduce early palliative care. IMPLICATIONS FOR PRACTICE Our findings have clinical, educational, and policy implications for fostering the conditions in which nurses are supported to maximize their full potential in the introduction of early palliative care.
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Affiliation(s)
- Shan Mohammed
- Author Affiliations: Lawrence S. Bloomberg Faculty of Nursing, University of Toronto (Dr Mohammed); Department of Supportive Care and Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network (Mss Swami and Pope, Drs Rodin and Zimmermann); and Division of Palliative Medicine (Dr Zimmermann), Division of Medical Oncology (Dr Zimmermann), and Department of Psychiatry (Dr Rodin), Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Moon CC, Mah K, Pope A, Swami N, Hannon B, Lau J, Mak E, Al-Awamer A, Banerjee S, Dawson LA, Husain A, Rodin G, Le LW, Zimmermann C. Family physicians' involvement in palliative cancer care. Cancer Med 2023; 12:6213-6224. [PMID: 36263836 PMCID: PMC10028020 DOI: 10.1002/cam4.5371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 09/21/2022] [Accepted: 10/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Family physicians' (FPs) long-term relationships with their oncology patients position them ideally to provide primary palliative care, yet their involvement is variable. We examined perceptions of FP involvement among outpatients receiving palliative care at a cancer center and identified factors associated with this involvement. METHODS Patients with advanced cancer attending an oncology palliative care clinic (OPCC) completed a 25-item survey. Eligible patients had seen an FP within 5 years. Binary multivariable logistic regression analyses were conducted to identify factors associated with (1) having seen an FP for palliative care within 6 months, and (2) having a scheduled/planned FP appointment. RESULTS Of 258 patients, 35.2% (89/253) had seen an FP for palliative care within the preceding 6 months, and 51.2% (130/254) had a scheduled/planned FP appointment. Shorter travel time to FP (odds ratio [OR] = 0.67, 95% confidence interval [CI] = 0.48-0.93, p = 0.02), the FP having a 24-h support service (OR = 1.96, 95% CI = 1.02-3.76, p = 0.04), and a positive perception of FP's care (OR = 1.05, 95% CI = 1.01-1.09, p = 0.01) were associated with having seen the FP for palliative care. English as a first language (OR = 2.90, 95% CI = 1.04-8.11, p = 0.04) and greater ease contacting FP after hours (OR = 1.33, 95% CI = 1.08-1.64, p = 0.008) were positively associated, and female sex of patient (OR = 0.51, 95% CI = 0.30-0.87, p = 0.01) and travel time to FP (OR = 0.66, 95% CI = 0.47-0.93, p = 0.02) negatively associated with having a scheduled/planned FP appointment. Number of OPCC visits was not associated with either outcome. CONCLUSION Most patients had not seen an FP for palliative care. Accessibility, availability, and equity are important factors to consider when planning interventions to encourage and facilitate access to FPs for palliative care.
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Affiliation(s)
- Christine C Moon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Kenneth Mah
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ashley Pope
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Nadia Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jenny Lau
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ernie Mak
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Al-Awamer
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Subrata Banerjee
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura A Dawson
- Department of Radiation Oncology, University of Toronto, Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Amna Husain
- Temmy Latner Centre for Palliative Care Lunenfeld Tanenbaum Research Institute, Sinai Health Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), University of Toronto and Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Lisa W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Alcalde Castro MJ, Zaig S, Nissim R, O'Connor B, Lau J, Mak E, Zimmermann C, Hannon B. Telehealth outpatient palliative care in the COVID-19 pandemic: patient experience qualitative study. BMJ Support Palliat Care 2023:spcare-2023-004189. [PMID: 36828625 DOI: 10.1136/spcare-2023-004189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/07/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVES Outpatient in-person early palliative care improves quality of life for patients with advanced cancer. The COVID-19 pandemic forced a rapid shift to telehealth visits; however, little is known about how telehealth in outpatient palliative care settings should be optimised beyond the pandemic. We aimed to explore, from the perspective of patients attending an outpatient palliative care clinic, the most appropriate model of care for in-person versus telehealth visits. METHODS A qualitative study using the grounded theory method. One-on-one, semistructured qualitative interviews were conducted with 26 patients attending an outpatient palliative care clinic at a tertiary cancer centre recruited from two groups: (1) those with >1 in-person appointment prior to 1 March 2020 and >1 telehealth appointment after this date (n=17); and (2) patients who had exclusively telehealth appointments (n=9). Purposive sampling was used to incorporate diverse perspectives. RESULTS Overall, participants endorsed a flexible hybrid approach incorporating both in-person and telehealth visits. Specific categories were: (1) in-person outpatient palliative care supported building interpersonal connections and trust; (2) telehealth palliative care facilitated greater efficiency, comfort and independence and (3) patient-preferred circumstances for in-person visits (preferred for initial consultations, visits where a physical examination may be required and advance care planning discussions), versus telehealth visits (preferred during periods of relative heath stability). CONCLUSIONS The elements of in-person and telehealth outpatient palliative care clinic visits described by patients as integral to their care may be used to develop models of hybrid outpatient palliative care delivery beyond the pandemic alongside reimbursement and regulatory guidelines.
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Affiliation(s)
| | - Shenhab Zaig
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Rinat Nissim
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Brenda O'Connor
- Department of Palliative Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jenny Lau
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ernie Mak
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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8
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Zimmermann C, Buss MK, Rabow MW, Hannon B, Hui D. Should Outpatient Palliative Care Clinics in Cancer Centers be Stand Alone or Embedded? J Pain Symptom Manage 2023; 65:e165-e170. [PMID: 36437178 DOI: 10.1016/j.jpainsymman.2022.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/05/2022] [Accepted: 11/07/2022] [Indexed: 11/27/2022]
Abstract
Outpatient palliative care facilitates timely symptom management, psychosocial care and care planning. A growing number of cancer centers have either stand-alone or embedded outpatient palliative care clinics. In this "Controversies in Palliative Care" article, three groups of thought leaders independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. One group advocates for stand-alone clinics, another for embedded, and the third group tries to find a balance. In the absence of evidence that directly compares the two models, factors such as cancer center size, palliative care team composition, clinic space availability, and financial considerations may drive the decision-making process at each institution. Stand-alone clinics may be more appropriate for larger academic cancer centers or palliative care programs with a more comprehensive interdisciplinary team, while embedded clinics may be more suited for smaller palliative care programs or community oncology programs to stimulate referrals. As outpatient clinic models continue to evolve, investigators need to document the referral and patient outcomes to inform practice.
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Affiliation(s)
- Camilla Zimmermann
- Department of Supportive Care (C.Z., B.H.), Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Palliative Care, Department of Medicine (C.Z., B.H.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine (C.Z., B.H.), University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health (C.Z.), University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care (M.K.B.), Tufts Medical Center, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (M.W.R.), University of California San Francisco, San Francisco, California, USA; Department of Palliative Care (D.H.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mary K Buss
- Department of Supportive Care (C.Z., B.H.), Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Palliative Care, Department of Medicine (C.Z., B.H.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine (C.Z., B.H.), University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health (C.Z.), University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care (M.K.B.), Tufts Medical Center, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (M.W.R.), University of California San Francisco, San Francisco, California, USA; Department of Palliative Care (D.H.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael W Rabow
- Department of Supportive Care (C.Z., B.H.), Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Palliative Care, Department of Medicine (C.Z., B.H.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine (C.Z., B.H.), University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health (C.Z.), University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care (M.K.B.), Tufts Medical Center, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (M.W.R.), University of California San Francisco, San Francisco, California, USA; Department of Palliative Care (D.H.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Breffni Hannon
- Department of Supportive Care (C.Z., B.H.), Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Palliative Care, Department of Medicine (C.Z., B.H.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine (C.Z., B.H.), University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health (C.Z.), University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care (M.K.B.), Tufts Medical Center, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (M.W.R.), University of California San Francisco, San Francisco, California, USA; Department of Palliative Care (D.H.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Supportive Care (C.Z., B.H.), Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Palliative Care, Department of Medicine (C.Z., B.H.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine (C.Z., B.H.), University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health (C.Z.), University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care (M.K.B.), Tufts Medical Center, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (M.W.R.), University of California San Francisco, San Francisco, California, USA; Department of Palliative Care (D.H.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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Lau J, Zimmermann C, Selby P, Furlan AD. Opioid Disposal Practices of Patients with Life-Limiting Cancers in an Outpatient Palliative Care Clinic: A Cross-Sectional Study. J Palliat Med 2023. [PMID: 36656166 DOI: 10.1089/jpm.2022.0355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Patients with life-limiting cancers are commonly prescribed opioids to manage pain, dyspnea, and cough. Proper prescription opioid disposal is essential to prevent poisonings and deaths. Objective: We examined opioid disposal practices of patients referred to a Canadian outpatient palliative care clinic (OPCC). The primary objective was to determine the prevalence of OPCC patients who did not routinely dispose their opioids. The secondary objectives were to examine their methods of opioid disposal and to identify patient characteristics associated with routine disposal of opioids. Design and Setting: This cross-sectional study involved a retrospective chart review of new, adult patients who were seen in a Canadian OPCC (September 2018-August 2019) and completed a survey about opioid-related constructs: source of prescriptions, use, storage, disposal, and knowledge about associated harms. Results: Among the 122 study participants, half (58/111, 52.3%) reported that they did not routinely dispose their opioids. The most common method of disposal was by giving them to pharmacists (69/88, 78.4%). Cannabis use (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 1.1-11.8) and neuropathic medication use (OR: 3.0, 95% CI: 1.2-7.2) were positively associated with routine disposal of opioids. Conversely, reports of an increased amount of opioid use in the past six months were negatively associated with routine disposal of opioids (OR: 0.38, 95% CI: 0.16-0.88). Conclusion: The high prevalence of people with life-limiting illnesses who do not routinely dispose their opioids requires increased attention. Interventions, such as education, are needed to reduce medication waste and opioid-related harms.
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Affiliation(s)
- Jenny Lau
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter Selby
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Andrea D Furlan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Institute for Work and Health, Toronto, Ontario, Canada
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10
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Nissim RS, Hales S. Caring for the Family Caregiver: Development of a Caregiver Clinic at a Cancer Hospital as Standard of Care. J Clin Psychol Med Settings 2022; 30:111-118. [PMID: 35699840 PMCID: PMC9195392 DOI: 10.1007/s10880-022-09891-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/27/2022]
Abstract
Family caregivers make significant contributions to the overall care of cancer patients and are the “invisible backbone” of the health care system. Family caregivers experience a wide range of challenges and can be considered patients in their own right, requiring support and dedicated attention, which may benefit them, the patients they are caring for, and the health care system. Despite consistent evidence on caregiver distress and unmet needs, most cancer care is organized around the patient as the target of care and caregiver distress is not screened for or addressed systematically. This article describes the development of a novel clinical, educational, and research program dedicated to supporting family caregivers at the Princess Margaret Cancer Center, Toronto, Canada and presents a model for a brief psychosocial intervention for caregivers. The objective of this article is to assist others in developing services to address the needs of family caregivers as a standard of care.
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Affiliation(s)
- Rinat S Nissim
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., Toronto, ON, M5G 2M9, Canada.
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Centre for Mental Health, University Health Network, Toronto, ON, Canada.
| | - Sarah Hales
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., Toronto, ON, M5G 2M9, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Mental Health, University Health Network, Toronto, ON, Canada
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11
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Shah R, Georgousopoulou EN, Al-Rubaie Z, Sulistio M, Tee H, Melia A, Michael N. Impact of ambulatory palliative care on symptoms and service outcomes in cancer patients: a retrospective cohort study. BMC Palliat Care 2022; 21:28. [PMID: 35241067 PMCID: PMC8896341 DOI: 10.1186/s12904-022-00924-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The integration of palliative care into routine cancer care has allowed for improved symptom control, relationship building and goal setting for patients and families. This study aimed to assess the efficacy of an ambulatory palliative care clinic on improving symptom burden and service outcomes for patients with cancer. METHODS A retrospective review of data of cancer patients who attended an ambulatory care clinic and completed the Symptom Assessment Scale between January 2015 and December 2019. We classified moderate to severe symptoms as clinically significant. Clinically meaningful improvement in symptoms (excluding pain) was defined by a ≥ 1-point reduction from baseline and pain treatment response was defined as a ≥ 2-point or ≥ 30% reduction from baseline. RESULTS A total of 249 patients met the inclusion criteria. The most common cancer diagnosis was gastrointestinal (32%) and the median time between the initial and follow-up clinic was 4 weeks. The prevalence of clinically significant symptoms at baseline varied from 28% for nausea to 88% for fatigue, with 23% of the cohort requiring acute admission due to unstable physical/psychosocial symptoms. There was significant improvement noted in sleep (p < 0.001), pain (p = 0.002), wellbeing (p < 0.001), and overall symptom composite scores (p = 0.028). Despite 18-28% of patients achieving clinically meaningful symptom improvement, 18-66.3% of those with moderate to severe symptoms at baseline continued to have clinically significant symptoms on follow-up. A third of patients had opioid and/or adjuvant analgesic initiated/titrated, with 39% educated on pain management. Goals of care (31%), insight (28%) and psychosocial/existential issues (27%) were commonly explored. CONCLUSIONS This study highlights the burden of symptoms in a cohort of ambulatory palliative care patients and the opportunity such services can provide for education, psychosocial care and future planning. Additionally routine screening of cohorts of oncology patients using validated scales may identify patients who would benefit from early ambulatory palliative care.
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Affiliation(s)
- Rajvi Shah
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, 154 Wattletree Road, Malvern, VIC, 3144, Australia.
- School of Medicine, Sydney Campus, University of Notre Dame Australia, Sydney, NSW, Australia.
| | - Ekavi N Georgousopoulou
- School of Medicine, Sydney Campus, University of Notre Dame Australia, Sydney, NSW, Australia
| | - Ziad Al-Rubaie
- School of Medicine, Sydney Campus, University of Notre Dame Australia, Sydney, NSW, Australia
| | - Merlina Sulistio
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, 154 Wattletree Road, Malvern, VIC, 3144, Australia
- School of Medicine, Sydney Campus, University of Notre Dame Australia, Sydney, NSW, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Hoong Tee
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, 154 Wattletree Road, Malvern, VIC, 3144, Australia
| | - Adelaide Melia
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, 154 Wattletree Road, Malvern, VIC, 3144, Australia
| | - Natasha Michael
- Supportive, Psychosocial and Palliative Care Research Department, Cabrini Health, 154 Wattletree Road, Malvern, VIC, 3144, Australia
- School of Medicine, Sydney Campus, University of Notre Dame Australia, Sydney, NSW, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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12
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Zimmermann C, Pope A, Hannon B, Krzyzanowska MK, Rodin G, Li M, Howell D, Knox JJ, Leighl NB, Sridhar S, Oza AM, Prince R, Lheureux S, Hansen AR, Rydall A, Chow B, Herx L, Booth CM, Dudgeon D, Dhani N, Liu G, Bedard PL, Mathews J, Swami N, Le LW. Phase II Trial of Symptom Screening With Targeted Early Palliative Care for Patients With Advanced Cancer. J Natl Compr Canc Netw 2021; 20:361-370.e3. [PMID: 34492632 DOI: 10.6004/jnccn.2020.7803] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/24/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Routine early palliative care (EPC) improves quality of life (QoL) for patients with advanced cancer, but it may not be necessary for all patients. We assessed the feasibility of Symptom screening with Targeted Early Palliative care (STEP) in a phase II trial. METHODS Patients with advanced cancer were recruited from medical oncology clinics. Symptoms were screened at each visit using the Edmonton Symptom Assessment System-revised (ESAS-r); moderate to severe scores (screen-positive) triggered an email to a palliative care nurse, who called the patient and offered EPC. Patient-reported outcomes of QoL, depression, symptom control, and satisfaction with care were measured at baseline and at 2, 4, and 6 months. The primary aim was to determine feasibility, according to predefined criteria. Secondary aims were to assess whether STEP identified patients with worse patient-reported outcomes and whether screen-positive patients who accepted and received EPC had better outcomes over time than those who did not receive EPC. RESULTS In total, 116 patients were enrolled, of which 89 (77%) completed screening for ≥70% of visits. Of the 70 screen-positive patients, 39 (56%) received EPC during the 6-month study and 4 (6%) received EPC after the study end. Measure completion was 76% at 2 months, 68% at 4 months, and 63% at 6 months. Among screen-negative patients, QoL, depression, and symptom control were substantially better than for screen-positive patients at baseline (all P<.0001) and remained stable over time. Among screen-positive patients, mood and symptom control improved over time for those who accepted and received EPC and worsened for those who did not receive EPC (P<.01 for trend over time), with no difference in QoL or satisfaction with care. CONCLUSIONS STEP is feasible in ambulatory patients with advanced cancer and distinguishes between patients who remain stable without EPC and those who benefit from targeted EPC. Acceptance of the triggered EPC visit should be encouraged. ClinicalTrials.gov identifier: NCT04044040.
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Affiliation(s)
- Camilla Zimmermann
- 1Department of Supportive Care, and.,2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,4Division of Palliative Medicine, Department of Medicine, and.,5Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto
| | | | - Breffni Hannon
- 1Department of Supportive Care, and.,2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,4Division of Palliative Medicine, Department of Medicine, and
| | - Monika K Krzyzanowska
- 2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,6Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto
| | - Gary Rodin
- 1Department of Supportive Care, and.,2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,5Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto
| | - Madeline Li
- 1Department of Supportive Care, and.,2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,5Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto
| | - Doris Howell
- 1Department of Supportive Care, and.,2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,7Faculty of Nursing, University of Toronto, Toronto
| | - Jennifer J Knox
- 2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,6Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto
| | - Natasha B Leighl
- 2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,6Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto
| | - Srikala Sridhar
- 2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,6Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto
| | - Amit M Oza
- 2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,6Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto
| | - Rebecca Prince
- 2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,6Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto
| | - Stephanie Lheureux
- 2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,6Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto
| | - Aaron R Hansen
- 2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,6Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto
| | | | | | - Leonie Herx
- 8Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston
| | - Christopher M Booth
- 9Division of Medical Oncology, Kingston Health Sciences Centre, Kingston.,10Department of Oncology, Queen's University, Kingston.,11Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston; and
| | - Deborah Dudgeon
- 9Division of Medical Oncology, Kingston Health Sciences Centre, Kingston
| | - Neesha Dhani
- 2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,6Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto
| | - Geoffrey Liu
- 2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,6Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto
| | - Philippe L Bedard
- 2Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto.,3Division of Medical Oncology.,6Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto
| | - Jean Mathews
- 1Department of Supportive Care, and.,4Division of Palliative Medicine, Department of Medicine, and
| | | | - Lisa W Le
- 12Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
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13
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Miyasaki JM, Lim SY, Chaudhuri KR, Antonini A, Piemonte M, Richfield E, Alburquerque Gonzalez D, Lorenzl S, Walker R, Bhidayasiri R, Bouca R, McConvey V. Access and Attitudes Toward Palliative Care Among Movement Disorders Clinicians. Mov Disord 2021; 37:182-189. [PMID: 34431560 DOI: 10.1002/mds.28773] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/14/2021] [Accepted: 08/04/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Neuropalliative care is an emerging field for those with neurodegenerative illnesses, but access to neuropalliative care remains limited. OBJECTIVE We sought to determine Movement Disorder Society (MDS) members' attitudes and access to palliative care. METHODS A quantitative and qualitative survey instrument was developed by the MDS Palliative Care Task Force and e-mailed to all members for completion. Descriptive statistics and qualitative analysis were triangulated. RESULTS Of 6442 members contacted, 652 completed the survey. Completed surveys indicating country of the respondent overwhelmingly represented middle- and high-income countries. Government-funded homecare was available to 54% of respondents based on patient need, 25% limited access, and 21% during hospitalization or an acute defined event. Eighty-nine percent worked in multidisciplinary teams. The majority endorsed trigger-based referrals to palliative care (75.5%), while 24.5% indicated any time after diagnosis was appropriate. Although 66% referred patients to palliative care, 34% did not refer patients. Barriers were identified by 68% of respondents, the most significant being available workforce, financial support for palliative care, and perceived knowledge of palliative care physicians specific to movement disorders. Of 499 respondents indicating their training in palliative care or desire to learn these skills, 55% indicated a desire to gain more skills. CONCLUSIONS The majority of MDS member respondents endorsed a role for palliative care in movement disorders. Many members have palliative training or collaborate with palliative care physicians. Although significant barriers exist to access palliative care, the desire to gain more skills and education on palliative care is an opportunity for professional development within the MDS. © 2021 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Janis M Miyasaki
- Parkinson and Movement Disorders Program, Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Shen-Yang Lim
- Division of Neurology, Department of Medicine, and the Mah Pooi Soo & Tan Chin Nam Centre for Parkinson's & Related Disorders, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - K Ray Chaudhuri
- Parkinson Foundation International Centre of Excellence, Kings College Hospital and Kings College, Denmark Hill Campus, London, United Kingdom
| | - Angelo Antonini
- Movement Disorders Unit-Center for Rare Neurological Diseases, Department of Neuroscience, University of Padua, Padua, Italy
| | - Maria Piemonte
- Physical Therapy, Speech Therapy, and Occupational Therapy Department, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Daniela Alburquerque Gonzalez
- Centro de Trastornos del Movimiento, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, Santiago, Chile
| | - Stefan Lorenzl
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria.,Ludwig-Maximillians-University, Munich, Germany.,Department of Neurology, Kliniku Agatharied, Hausham, Germany
| | - Richard Walker
- Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,The Academy of Science, The Royal Society of Thailand, Bangkok, Thailand
| | - Raquel Bouca
- Instituto de Medicina Molecular Joao Lobo Antunes, Lisbon, Portugal
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14
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Abstract
PURPOSE OF REVIEW Supportive care services have evolved overtime to meet the growing supportive care need of patients with cancer and their families. In this review, we summarize existing definitions of supportive care, highlight empiric studies on supportive care delivery, and propose an integrated conceptual framework on supportive cancer care. RECENT FINDINGS Supportive care aims at addressing the patients' physical, emotional, social, spiritual, and informational needs throughout the disease trajectory. Interdisciplinary teams are needed to deliver multidimensional care. Oncology teams have an important role providing supportive care in the front lines and referring patients to supportive care services such as palliative care, social work, rehabilitation, psycho-oncology, and integrative medicine. However, the current model of as needed referral and siloed departments can lead to heterogeneous access and fragmented care. To overcome these challenges, we propose a conceptual model in which supportive care services are organized under one department with a unified approach to patient care, program development, and research. Key features of this model include universal referral, systematic screening, tailored specialist involvement, streamlined care, collaborative teamwork, and enhanced outcomes. SUMMARY Further research is needed to develop and test innovative supportive care models that can improve patient outcomes.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
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15
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Mathews J, Hannon B, Zimmermann C. Models of Integration of Specialized Palliative Care with Oncology. Curr Treat Options Oncol 2021; 22:44. [PMID: 33830352 PMCID: PMC8027976 DOI: 10.1007/s11864-021-00836-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT Evidence from randomized controlled trials and meta-analyses has shown that early integration of specialized palliative care improves symptoms and quality of life for patients with advanced cancer. There are various models of early integration, which may be classified based on setting of care and method of palliative care referral. Most successful randomized controlled trials of early palliative care have used a model of specialized teams providing in-person palliative care in free-standing or embedded outpatient clinics. During the COVID-19 pandemic, telehealth has become a prominent model for palliative care delivery. This model of care has been well received by patients and palliative care providers, although evidence to date is limited. Despite evidence from trials that routine early integration of palliative care into oncology care improves patient outcomes, referral to palliative care still occurs mostly according to the judgment of individual oncologists. This hinders equitable access to palliative care and to its known benefits for patients and their caregivers. Automated referral based on triggering criteria is being actively explored as an alternative. In particular, routine technology-assisted symptom screening, combined with targeted needs-based automatic referral to outpatient palliative care, may improve integration and ultimately increase quality of life.
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Affiliation(s)
- Jean Mathews
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
- Divisions of Palliative Medicine and Medical Oncology, University of Toronto, Toronto, Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada
- Divisions of Palliative Medicine and Medical Oncology, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave., 16-712, Toronto, Ontario, M5G 2M9, Canada.
- Divisions of Palliative Medicine and Medical Oncology, University of Toronto, Toronto, Canada.
- Department of Medicine, University of Toronto, Toronto, Canada.
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16
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Supporting the Needs of Adolescents and Young Adults: Integrated Palliative Care and Psychiatry Clinic for Adolescents and Young Adults with Cancer. Cancers (Basel) 2021; 13:cancers13040770. [PMID: 33673202 PMCID: PMC7918814 DOI: 10.3390/cancers13040770] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/28/2021] [Accepted: 02/08/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Adolescents and young adults (AYAs) with cancer experience a high level of distress and have unique unmet palliative and supportive care needs. There is limited knowledge about the symptom burden, quality of life, and type of care that AYA patients receive. In 2017, a dedicated AYA-specialized palliative care clinic was established at Princess Margaret Cancer Centre in Canada, with a collaborative approach between palliative care and psychiatry. This study aims to describe the demographics and symptoms burden of AYA cancer patients who attended the integrated palliative care and psychiatry clinic, measure the impact of the clinic on AYAs’ symptom control, and examine their end-of-life outcomes. Abstract Clinical guidelines aimed at cancer care for adolescents and young adults (AYAs) encourage early integration of palliative care, yet there are scarce data to support these recommendations. We conducted a retrospective chart review of AYA patients, aged 15 to 39 years, who were referred to the Integrated AYA Palliative Care and Psychiatry Clinic (IAPCPC) at the Princess Margaret Cancer Centre between May 2017 and November 2019 (n = 69). Demographic data, symptom prevalence, change in symptom scores between baseline consultation and first follow-up, and intensity of end-of-life care were collected from the patients’ medical charts, analyzed, and reported. Of the 69 patients, 59% were female, and sarcoma was the most common cancer. A majority of patients had at least one symptom scored as moderate to severe; tiredness, pain, and sleep problems were the highest scored symptoms. More than one-third used medical cannabis to manage their symptoms. Symptom scores improved in 61% after the first clinic visit. Out of the 69 patients, 50 (72.5%) had died by October 2020, with a median time between the initial clinic referral and death of 5 months (range 1–32). Three patients (6%) received chemotherapy, and eight (16%) were admitted to an intensive care unit during the last month of life. In conclusion, AYAs with advanced cancer have a high burden of palliative and psychosocial symptoms. Creating a specialized AYA palliative care clinic integrated with psychiatry showed promising results in improving symptom scores and end-of-life planning.
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17
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Hannon B, Mak E, Al Awamer A, Banerjee S, Blake C, Kaya E, Lau J, Lewin W, O'Connor B, Saltman A, Zimmermann C. Palliative care provision at a tertiary cancer center during a global pandemic. Support Care Cancer 2020; 29:2501-2507. [PMID: 32929539 PMCID: PMC7490111 DOI: 10.1007/s00520-020-05767-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/08/2020] [Indexed: 01/08/2023]
Abstract
COVID-19 was first reported in Wuhan, China, in December 2019; it rapidly spread around the world and was declared a global pandemic by the World Health Organization in March 2020. The palliative care program at the Princess Margaret Cancer Centre, Toronto, Canada, provides comprehensive care to patients with advanced cancer and their families, through services including an acute palliative care unit, an inpatient consultation service, and an ambulatory palliative care clinic. In the face of a global pandemic, palliative care teams are uniquely placed to support patients with cancer who also have COVID-19. This may include managing severe symptoms such as dyspnea and agitation, as well as guiding advance care planning and goals of care conversations. In tandem, there is a need for palliative care teams to continue to provide care to patients with advanced cancer who are COVID-negative but who are at higher risk of infection and adverse outcomes related to COVID-19. This paper highlights the unique challenges faced by a palliative care team in terms of scaling up services in response to a global pandemic while simultaneously providing ongoing support to their patients with advanced cancer at a tertiary cancer center.
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Affiliation(s)
- Breffni Hannon
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada. .,Department of Medicine, University of Toronto, Toronto, Canada.
| | - Ernie Mak
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Ahmed Al Awamer
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Subrata Banerjee
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Christopher Blake
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Ebru Kaya
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Jenny Lau
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Warren Lewin
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Brenda O'Connor
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Alexandra Saltman
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
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18
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Pilz MJ, Aaronson NK, Arraras JI, Caocci G, Efficace F, Groenvold M, Holzner B, van Leeuwen M, Loth FLC, Petersen MA, Ramage J, Tomaszewski KA, Young T, Giesinger JM. Evaluating the Thresholds for Clinical Importance of the EORTC QLQ-C15-PAL in Patients Receiving Palliative Treatment. J Palliat Med 2020; 24:397-404. [PMID: 32835601 DOI: 10.1089/jpm.2020.0159] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: The EORTC QLQ-C15-PAL is a shortened version of the widely used EORTC QLQ-C30. This questionnaire was developed to measure the symptoms and functional health of patients receiving palliative care. Objective: To enhance clinical interpretability of the EORTC QLQ-C15-PAL, our aim was to evaluate the sensitivity and specificity of thresholds for clinical importance developed previously for the QLQ-C30 when applied to the QLQ-C15-PAL scales. Design: Cross-sectional observational study. Setting/Subjects: Patients with cancer receiving any type of palliative treatment. Measurement: Patients completed the EORTC QLQ-C15-PAL and anchor items on limitations, worries, and need for help for each of the health domains covered by the questionnaire. The anchor items were summarized in a binary criterion for clinical importance to calculate the sensitivity and specificity of the thresholds for clinical importance. Results: In total, 225 patients participated in the study (mean age 64.5 years). Patients were recruited from Austria, Italy, the Netherlands, Poland, Spain, and the United Kingdom. The thresholds for clinical importance for the QLQ-C15-PAL scales showed a median sensitivity of 0.88 (range: 0.82 for sleep disturbances to 1.00 for dyspnea) and a median specificity of 0.74 (range: 0.54 for dyspnea to 0.89 for constipation). Conclusion: The thresholds for clinical importance showed high sensitivity and mostly high specificity in identifying clinically important symptoms and functional health impairments as assessed by the QLQ-C15-PAL. These thresholds will facilitate interpretation of EORTC QLQ-C15-PAL scores in daily clinical practice and clinical research.
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Affiliation(s)
- Micha J Pilz
- University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
| | - Neil K Aaronson
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Juan I Arraras
- Oncology Departments, Complejo Hospitalario of Navarre, Pamplona, Spain
| | - Giovanni Caocci
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Fabio Efficace
- Health Outcomes Research Unit, Italian Group for Adult Hematologic Diseases (GIMEMA) Data Center, Rome, Italy
| | - Mogens Groenvold
- The Palliative Care Research Unit, Department of Geriatrics and Palliative Medicine GP, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Bernhard Holzner
- University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
| | - Marieke van Leeuwen
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Fanny L C Loth
- Department of Psychosomatic Medicine and Psychotherapy, Simssee Clinic Bad Endorf, Bad Endorf, Germany
| | - Morten Aa Petersen
- The Palliative Care Research Unit, Department of Geriatrics and Palliative Medicine GP, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - John Ramage
- Department of Gastroenterology and Hepatology, Hampshire Hospitals NHS Foundation Trust, Basingstoke, United Kingdom
| | - Krzysztof A Tomaszewski
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland.,Scanmed St. Raphael Hospital, Krakow, Poland
| | - Teresa Young
- Lynda Jackson Macmillan Centre, East and North Hertfordshire NHS Trust Incorporating Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Johannes M Giesinger
- University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
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19
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Alam S, Pope A, Le L, Al-Awamer A, Banerjee S, Lau J, Mak E, Zimmermann C, Hannon B. Outpatient palliative medicine consultations: urgent or routine? BMJ Support Palliat Care 2020; 11:149-155. [PMID: 32527786 DOI: 10.1136/bmjspcare-2020-002201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/16/2020] [Accepted: 05/12/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although outpatient palliative care clinics (OPCCs) provide a venue for early, pre-emptive referral to palliative care on a routine basis, some patients will continue to require urgent referrals. The purpose of this study was to characterise these urgent referrals to determine whether they reflect clinical need or convenience. METHODS We retrospectively compared new patients in an OPCC who were seen urgently versus those seen at routine appointments. Descriptive statistics compared the two groups in terms of clinical characteristics, referring teams, symptoms, performance status and outcomes. Logistic regression was used to identify factors associated with urgent referral to the OPCC. Overall survival was compared using the log-rank test. RESULTS Between January 2016 and December 2017, a total of 113 urgent referrals were reviewed in the OPCC; these were compared with a random sample of 217 routine referrals. Patients seen urgently were more likely to be referred by surgical oncology, and to report worse symptom scores for pain (p=0.0007), tiredness (p=0.02), well-being (p=0.001), constipation (p=0.02) and sleep (p=0.01). More patients seen urgently required direct admission to hospital following the visit (17.7% vs 0.9%, p<0.001). Median survival was shorter for patients seen urgently (4.3 months, 95% CI 3.4 to 7.8) versus routinely (8.1 months, 95% CI 7.2 to 9.5). CONCLUSIONS Compared with routine referrals, new patients seen urgently in the OPCC had higher symptom burden, shorter median survival and a greater chance of direct admission to hospital. Palliative care clinics should consider how best to accommodate urgent referrals.
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Affiliation(s)
- Sorayya Alam
- Palliative Medicine, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Ashley Pope
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Lisa Le
- Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ahmed Al-Awamer
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Subrata Banerjee
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jenny Lau
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ernie Mak
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Breffni Hannon
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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20
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Brenne AT, Knudsen AK, Raj SX, Skjelvan L, Lund JÅ, Thronæs M, Løhre ET, Hågensen LÅ, Brunelli C, Kaasa S. Fully Integrated Oncology and Palliative Care Services at a Local Hospital in Mid-Norway: Development and Operation of an Innovative Care Delivery Model. Pain Ther 2020; 9:297-318. [PMID: 32274655 PMCID: PMC7203320 DOI: 10.1007/s40122-020-00163-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Early access to cancer palliative care is recommended. Descriptions of structures and processes of outpatient palliative care clinics operated within smaller hospitals are scarce. This paper presents the development and operation of a fully integrated cancer and palliative care outpatient clinic at a local hospital in a rural region of Mid-Norway offering palliative care concurrent with cancer treatment. A standardized care pathway was applied. METHODS Palliative care is in Norway part of the public healthcare system. Official recommendations recent years point out action points to improve delivery of palliative care. An integrated cancer and palliative care outpatient clinic at a local hospital and an innovative care delivery model was developed and operated in this setting. Patients were recruited for a descriptive study of the patient population. Clinical data were collected by clinical staff and 13 symptom intensities were reported by the patients. RESULTS Cancer and palliative care were provided by one team of healthcare professionals trained in both fields. There was a close collaboration with the other departments at the hospital, with its affiliated tertiary hospital, and with community health and care services to provide timely referral, enhanced continuity, and improved coordination of care. Eighty-eight patients were included. Mean age was 65.6 years, the most common cancer diagnoses were digestive organs (22.7%), male genital organs (20.5%) or breast (25.0%), 75.0% had metastatic or locally advanced cancer, 59.1% were treated with non-curative intention and 93.1% had Karnofsky Performance Status ≥ 80%. Median scores of individual symptoms ranged from 0 to 3 (numerical rating scale, 0-10) and 61.0% reported at least one clinically significant symptom rating (≥ 4). CONCLUSION This delivery model of integrated outpatient cancer and palliative care is particularly relevant in rural regions allowing cancer patients access to palliative care earlier in the disease trajectory and closer to home.
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Affiliation(s)
- Anne-Tove Brenne
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Anne Kari Knudsen
- European Palliative Care Research Centre (PRC), Oslo University Hospital and University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Sunil Xavier Raj
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Laila Skjelvan
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Jo-Åsmund Lund
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Oncology, Ålesund Hospital, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | - Morten Thronæs
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Erik Torbjørn Løhre
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | - Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Instituto Nazionale dei Tumori, Milan, Italy
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Oslo University Hospital and University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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21
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Mah K, Swami N, Le LW, Chow R, Hannon BL, Rodin G, Zimmermann C. Validation of the 7-item Functional Assessment of Cancer Therapy-General (FACT-G7) as a short measure of quality of life in patients with advanced cancer. Cancer 2020; 126:3750-3757. [PMID: 32459377 DOI: 10.1002/cncr.32981] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/17/2020] [Accepted: 03/28/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Assessing quality of life is essential for individuals with advanced cancer, but lengthy assessments can be burdensome. The authors investigated the psychometric characteristics of the FACT-G7, a 7-item quality-of-life measure derived from the Functional Assessment of Cancer Therapy-General (FACT-G) scale, in advanced cancer. METHODS Data were obtained from outpatients with advanced cancer who were enrolled in a randomized controlled trial of early palliative care. At baseline, 228 intervention participants and 233 control participants (N = 461) completed the FACT-G and measures of symptom severity, quality of life near the end of life, problematic medical communication, and satisfaction with care. Follow-up measures were administered monthly for 4 months. RESULTS The FACT-G7 showed good internal consistency (Cronbach α = .72-.80), and its single-factor structure was supported. It correlated strongly with the FACT-G total, physical, and functional indices and with symptom severity (absolute r = 0.73-0.92); more moderately with the FACT-G emotional index and with symptom impact and preparation for the end of life (r = .40-.71); and least with the FACT-G social/family index and with relationship with health care provider, life completion, problematic medical communication, and care satisfaction measures (absolute r = .26-.44). Eastern Cooperative Oncology Group performance status groups differed on FACT-G7 scores, as expected (all P < .001). Improvements in FACT-G7 scores in the intervention group compared with the control group at 3-month (P = .049) and 4-month (P = .034) follow-up supported responsiveness to change and somewhat greater sensitivity than the FACT-G scores. CONCLUSIONS The FACT-G7 is a valid, brief measure particularly of the physical and functional facets of quality of life. It may enable rapid quality-of-life assessments in patients with advanced cancer.
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Affiliation(s)
- Kenneth Mah
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Nadia Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Lisa W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ronald Chow
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Breffni L Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Abstract
Family caregivers provide substantial care for patients with advanced cancer, while suffering from hidden morbidity and unmet needs. The objectives of this review were to examine risk factors associated with caregiving for patients with advanced cancer, evaluate the evidence for pertinent interventions, and provide a practical framework for palliative care of caregivers in oncology settings. We reviewed studies examining the association of factors at the level of the caregiver, patient, caregiver-patient relationship, and caregiving itself, with adverse outcomes. In addition, we reviewed randomized controlled trials of interventions targeting the caregiver, the caregiver-patient dyad, or the patient and their family. Risk factors for adverse mental health outcomes included those related to the patient's declining status, symptom distress, and poor prognostic understanding; risk factors for adverse bereavement outcomes included unfavorable circumstances of the patient's death. Among the 16 randomized trials, the most promising results showed improvement of depression resulting from early palliative care interventions; results for quality of life were generally nonsignificant or showed an effect only on some subscales. Caregiving outcomes included burden, appraisal, and competence, among others, and showed mixed findings. Only three trials measured bereavement outcomes, with mostly nonsignificant results. On the basis of existent literature and our clinical experience, we propose the CARES framework to guide care for caregivers in oncology settings: Considering caregivers as part of the unit of care, Assessing the caregiver's situation and needs, Referring to appropriate services and resources, Educating about practical aspects of caregiving, and Supporting caregivers through bereavement. Additional trials are needed that are powered specifically for caregiver outcomes, use measures validated for advanced cancer caregivers, and test real-world interventions.
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Affiliation(s)
- Sorayya Alam
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Breffni Hannon
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
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23
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Abstract
Palliative care has evolved over the past five decades as an interprofessional specialty to improve quality of life and quality of care for patients with cancer and their families. Existing evidence supports that timely involvement of specialist palliative care teams can enhance the care delivered by oncology teams. This review provides a state-of-the-science synopsis of the literature that supports each of the five clinical models of specialist palliative care delivery, including outpatient clinics, inpatient consultation teams, acute palliative care units, community-based palliative care, and hospice care. The roles of embedded clinics, nurse-led models, telehealth interventions, and primary palliative care also will be discussed. Outpatient clinics represent the key point of entry for timely access to palliative care. In this setting, patient care can be enhanced longitudinally through impeccable symptom management, monitoring, education, and advance care planning. Inpatient consultation teams provide expert symptom management and facilitate discharge planning for acutely symptomatic hospitalized patients. Patients with the highest level of distress and complexity may benefit from an admission to acute palliative care units. In contrast, community-based palliative care and hospice care are more appropriate for patients with a poor performance status and low to moderate symptom burden. Each of these five models of specialist palliative care serve a different patient population along the disease continuum and complement one another to provide comprehensive supportive care. Additional research is needed to define the standards for palliative care interventions and to refine the models to further improve access to quality palliative care.
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Affiliation(s)
- David Hui
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- University of Texas MD Anderson Cancer Center, Houston, TX
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24
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Mohammed S, Savage P, Kevork N, Swami N, Rodin G, Zimmermann C. "I'm going to push this door open. You can close it": A qualitative study of the brokering work of oncology clinic nurses in introducing early palliative care. Palliat Med 2020; 34:209-218. [PMID: 31659940 DOI: 10.1177/0269216319883980] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early palliative care improves quality of life during life-prolonging treatment for patients with cancer, but the role of nurses in facilitating the early involvement of palliative care is unclear. AIM To conceptualize the psychosocial processes involved in the introduction and provision of palliative care by oncology nurses. DESIGN A constructivist qualitative grounded theory study was conducted. SETTING/PARTICIPANTS A total of 20 nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) completed semi-structured interviews. Participants were from multiple ambulatory care oncology clinics (i.e. breast, pancreatic, hematology) in a comprehensive cancer center. RESULTS The core category, brokering palliative care, represented the overarching concept of the study that linked other subcategories. The other subcategories were as follows: opening the door-creating the possibility of discussing early palliative care at a time when patients show signs of being receptive to this discussion; building trust-establishing relationships with patients as a starting point for open discussions about palliative care; tackling misconceptions-addressing patients' assumptions about palliative care as signifying death; and advocating with oncologists-seeding the process of referral by bringing patients' concerns forward. CONCLUSION Oncology nurses play a central role in "brokering" the introduction of early palliative care; this process is supported by their relational proximity to patients and their location "in between" the patient and the oncologist. Training all nurses in palliative care and empowering them to have proactive discussions in a collaborative practice context would allow greater access to early palliative care.
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Affiliation(s)
- Shan Mohammed
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Pamela Savage
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Nanor Kevork
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Nadia Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Divisions of Palliative Medicine and Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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25
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Lau J, Flamer D, Murphy-Kane P. Interventional anesthesia and palliative care collaboration to manage cancer pain: a narrative review. Can J Anaesth 2020; 67:235-246. [PMID: 31571119 DOI: 10.1007/s12630-019-01482-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 12/20/2022] Open
Abstract
Pain is a common symptom associated with advanced cancer. An estimated 66.4% of people with advanced cancer experience pain from their disease or treatment. Pain management is an essential component of palliative care. Opioids and adjuvant therapies are the mainstay of cancer pain management. Nevertheless, a proportion of patients may experience complex pain that is not responsive to conventional analgesia. Interventional analgesia procedures may be appropriate and necessary to manage complex, cancer-related pain. This narrative review uses a theoretical case to highlight core principles of palliative care and interventional anesthesia, and the importance of collaborative, interdisciplinary care. An overview and discussion of pragmatic considerations of peripheral nervous system interventional analgesic procedures and neuraxial analgesia infusions are provided.
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Affiliation(s)
- Jenny Lau
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.
- Acute Palliative Care Unit, Princess Margaret Cancer Center, Toronto, ON, Canada.
- Division of Palliative Care, Department of Family and Community Medicine, Toronto, ON, Canada.
| | - David Flamer
- Department of Anesthesia and Pain Medicine, University Health Network, Toronto, ON, Canada
- Toronto Western Hospital, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Patricia Murphy-Kane
- Department of Supportive Care, University Health Network, Toronto, ON, Canada
- Acute Palliative Care Unit, Princess Margaret Cancer Center, Toronto, ON, Canada
- Department of Nursing, Princess Margaret Cancer Center, Toronto, ON, Canada
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26
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Hassankhani H, Rahmani A, Taleghani F, Sanaat Z, Dehghannezhad J. Palliative Care Models for Cancer Patients: Learning for Planning in Nursing (Review). JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2020; 35:3-13. [PMID: 31020622 DOI: 10.1007/s13187-019-01532-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Cancer is the second cause of mortality in the world. Increased incidence of cancer and its growing trend have drawn attention to care for these patients. Palliative care is a solution for improving the quality of cancer care. However, only 14% of cancer patients in the world are receiving palliative care and most nurses lack the adequate knowledge and education to implement different palliative care models for cancer patients. This review of the literature intended to identify the palliative care models used by nurses for cancer patients as well as the similarities and differences between these models. Databases such as PubMed, ProQuest, google scholar, and CINAHL were searched, and experimental studies that presented palliative care models for cancer patients that nurses were involved were selected. From a total of articles selected by searching the databases, 16 experimental articles were selected. These articles presented 12 palliative care models that involved nurses and participants were cancer patients. The palliative care models presented in the experimental articles were based on hospice, hospital, home care, ambulatory, community, pediatric, spirituality, early, family, telehealth, dignity, and integrated. It was found out that several palliative care nursing models for cancer patients can be employed by nurses as they are the key agents in the provision of palliative care. The collaborative nature of the models, their positive consequences for patients being common components of models, and the implementation of the models considering the disease trajectory were among their distinctions.
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Affiliation(s)
- Hadi Hassankhani
- Medical-surgical Department, Nursing & Midwifery Faculty, Center of Qualitative Studies, School of Nursing and Midwifery, Tabriz University of Medical Sciences, South Shariati Street, Tabriz, East Azerbaijan Province, Iran
| | - Azad Rahmani
- Medical-surgical Department, Nursing & Midwifery Faculty, Medical Education Research Center, Tabriz University of Medical Sciences, South Shariati Street, Tabriz, East Azerbaijan Province, Iran
| | - Fariba Taleghani
- Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Hezarjereeb Avenue, Isfahan, Iran
| | - Zohreh Sanaat
- Department of Hematology and Oncology, Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Javad Dehghannezhad
- Medical-surgical Department, Nursing & Midwifery Faculty, Tabriz University of Medical Sciences, South Shariati Street, Tabriz, East Azerbaijan Province, Iran.
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27
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Berry LL, Crane J, Deming KA, Barach P. Using Evidence to Design Cancer Care Facilities. Am J Med Qual 2020; 35:397-404. [DOI: 10.1177/1062860619897406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The nuts and bolts of planning and designing cancer care facilities—the physical space, the social systems, the clinical and nonclinical workflows, and all of the patient-facing services—directly influence the quality of clinical care and the overall patient experience. Cancer facilities should be conceived and constructed on the basis of evidence-based design thinking and implementation, complemented by input from key stakeholders such as patients, families, and clinicians. Specifically, facilities should be designed to improve the patient experience, offer options for urgent care, maximize infection control, support and streamline the work of multidisciplinary teams, integrate research and teaching, incorporate palliative care, and look beyond mere diagnosis and treatment to patient wellness—all tailored to each cancer center’s patient population and logistical and financial constraints. From conception to completion to iterative reevaluation, motivated institutions can learn to make their own facilities reflect the excellence in cancer care that they aim to deliver to patients.
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Affiliation(s)
- Leonard L. Berry
- Texas A&M University, College Station, TX
- Institute for Healthcare Improvement, Boston, MA
| | | | | | - Paul Barach
- Wayne State University, Detroit, MI
- Jefferson College of Population Health, Philadelphia, PA
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28
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Fliedner M, Zambrano S, Schols JM, Bakitas M, Lohrmann C, Halfens RJ, Eychmüller S. An early palliative care intervention can be confronting but reassuring: A qualitative study on the experiences of patients with advanced cancer. Palliat Med 2019; 33:783-792. [PMID: 31068119 DOI: 10.1177/0269216319847884] [Citation(s) in RCA: 15] [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] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intervention trials confirm that patients with advanced cancer receiving early palliative care experience a better quality of life and show improved knowledge about and use of palliative care services. To involve patients in future health-care decisions, health professionals should understand patients' perspectives. However, little is known about how patients' experience such interventions. AIM To explore advanced cancer patients' experiences with a structured early palliative care intervention, its acceptability and impact on the patients' life including influencing factors. DESIGN Qualitative content analysis of in-depth, semi-structured interviews. SETTING/PARTICIPANTS Patients with various advanced cancer diagnoses were enrolled in a multicenter randomized controlled trial (NCT01983956), which investigated the impact of "Symptoms, End-of-life decisions, Network, Support," a structured early palliative care intervention, on distress. Of these, 20 patients who underwent the intervention participated in this study. RESULTS Participants received the intervention well and gained a better understanding of their personal situation. Patients reported that the intervention can feel "confronting" but with the right timing it can be confirming and facilitate family conversations. Patients' personal background and the intervention timing within their personal disease trajectory influenced their emotional and cognitive experiences; it also impacted their understanding of palliative care and triggered actions toward future care planning. CONCLUSION Early palliative care interventions like "Symptoms, End-of-life decisions, Network, Support" may provoke emotions and feel "confrontational" often because this is the first time when issues about one's end of life are openly discussed; yet, advanced cancer patients found it beneficial and felt it should be incorporated into routine care.
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Affiliation(s)
- Monica Fliedner
- 1 DOLS, University Center for Palliative Care, University Hospital Inselspital Bern, Bern, Switzerland
- 2 Department of Health Services Research, School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Sofia Zambrano
- 1 DOLS, University Center for Palliative Care, University Hospital Inselspital Bern, Bern, Switzerland
| | - Jos Mga Schols
- 2 Department of Health Services Research, School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
- 3 Department of Family Medicine, School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Marie Bakitas
- 4 School of Nursing, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Christa Lohrmann
- 5 Institute of Nursing Science, University of Graz, Graz, Austria
| | - Ruud Jg Halfens
- 2 Department of Health Services Research, School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Steffen Eychmüller
- 1 DOLS, University Center for Palliative Care, University Hospital Inselspital Bern, Bern, Switzerland
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29
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Beasley AM, Bakitas MA, Ivankova N, Shirey MR. Evolution and Conceptual Foundations of Nonhospice Palliative Care. West J Nurs Res 2019; 41:1347-1369. [DOI: 10.1177/0193945919853162] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The term nonhospice palliative care was developed to describe and differentiate palliative care that is delivered prior to the end of life. The purpose of this article is to better define and clarify this concept using Rodgers’s evolutionary concept analysis method. Attributes of nonhospice palliative care include (a) patient- and family-centered care, (b) holistic care, (c) interdisciplinary team, (d) early intervention, (e) quality of life-enhancing, (f) advanced care planning, (g) any age of the patient, (h) at any stage in illness, (i) care coordination, (j) concurrent curative treatment options, and (k) provided by primary and specialist providers. Nonhospice palliative care antecedents are serious illness, education, and access to services; consequences include benefits for the patient, family, provider, and health care system. Offering a clearly defined concept may allow for changes in health care to improve access to these services.
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30
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Emotion And Symptom-focused Engagement (EASE): a randomized phase II trial of an integrated psychological and palliative care intervention for patients with acute leukemia. Support Care Cancer 2019; 28:163-176. [DOI: 10.1007/s00520-019-04723-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/27/2019] [Indexed: 02/01/2023]
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31
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Serpentini S, Del Bianco P, Chirico A, Merluzzi TV, Martino R, Lucidi F, De Salvo GL, Trentin L, Capovilla E. Self-efficacy for coping: utility of the Cancer behavior inventory (Italian) for use in palliative care. BMC Palliat Care 2019; 18:34. [PMID: 30953485 PMCID: PMC6449975 DOI: 10.1186/s12904-019-0420-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 03/27/2019] [Indexed: 11/25/2022] Open
Abstract
Background Newer models of palliative and supportive cancer care view the person as an active agent in managing physical and psychosocial challenges. Therefore, personal efficacy is an integral part of this model. Due to the lack of instruments in Italian to assess coping self-efficacy, the present study included the translation and validation of the Italian version of the Cancer Behavior Inventory–Brief (CBI-B/I) and an initial analysis of the utility of self-efficacy for coping in an Italian sample of palliative care patients. Methods 216 advanced cancer patients who attended palliative care clinics were enrolled. The CBI-B/I was administered along with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), the Mini Mental Adjustment to Cancer Scale (Mini-MAC), the Cancer Concerns Checklist (CCL), and the Hospital Anxiety and Depression Scale (HADS). The Eastern Cooperative Oncology Group Performance Status (ECOG-PS) ratings of functional capacity were completed by physicians. Results Factor analysis confirmed that the structure of the CBI-B/I was consistent with the English version. Internal consistency reliability and significant correlations with the EORTC QLQ-C30, Mini-MAC, and HADS supported the concurrent validity of the CBI-B/I. Differences in CBI-B/I scores for high versus low levels of the CCL and ECOG-PS supported the clinical utility of the CBI-B/I. Conclusions The CBI-B/I has strong psychometric properties and represents an important addition to newer model of palliative and supportive care. In order to improve clinical practice, the CBI-B/I could be useful in identifying specific self-efficacy goals for coping in structured psychosocial interventions.
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Affiliation(s)
- Samantha Serpentini
- Istituto Oncologico Veneto IOV - IRCCS, Via Gattamelata, 64, 35128, Padova, Italy.
| | - Paola Del Bianco
- Istituto Oncologico Veneto IOV - IRCCS, Via Gattamelata, 64, 35128, Padova, Italy
| | | | | | - Rosalba Martino
- Istituto Oncologico Veneto IOV - IRCCS, Via Gattamelata, 64, 35128, Padova, Italy
| | | | - Gian Luca De Salvo
- Istituto Oncologico Veneto IOV - IRCCS, Via Gattamelata, 64, 35128, Padova, Italy
| | - Leonardo Trentin
- Istituto Oncologico Veneto IOV - IRCCS, Via Gattamelata, 64, 35128, Padova, Italy
| | - Eleonora Capovilla
- Istituto Oncologico Veneto IOV - IRCCS, Via Gattamelata, 64, 35128, Padova, Italy
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Sarradon-Eck A, Besle S, Troian J, Capodano G, Mancini J. Understanding the Barriers to Introducing Early Palliative Care for Patients with Advanced Cancer: A Qualitative Study. J Palliat Med 2019; 22:508-516. [PMID: 30632886 DOI: 10.1089/jpm.2018.0338] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Palliative care is often underutilized or initiated late in the course of life-threatening illness. Randomized clinical Early Palliative Care (EPC) trials provide an opportunity for changing oncologists' perceptions of palliative care and their attitudes to referring patients to palliative care services. Aim: To describe French oncologists' perceptions of EPC and their effects on referral practices before a clinical EPC trial was launched. Design: A qualitative study involving semistructured face-to-face interviews. The data were analyzed using the Grounded Theory coding method. Setting/Participants: Thirteen oncologists and 19 palliative care specialists (PCSs) working at 10 hospitals all over France were interviewed. Most of them were involved in clinical EPC trials. Results: The findings suggest that referral to PCSs shortly after the diagnosis of advanced cancer increases the terminological barriers, induces avoidance patterns, and makes early disclosure of poor prognosis harder for oncologists. This situation is attributable to the widespread idea that palliative care means terminal care. In addition, the fact that the EPC concept is poorly understood increases the confusion between EPC and supportive care. Conclusion: Defining the EPC concept more clearly and explaining to health professionals and patients what EPC consists of and what role it is intended to play, and the potential benefits of palliative care services could help to overcome the wording barriers rooted in the traditional picture of palliative care. In addition, training French oncologists how to disclose "bad news" could help them cope with the emotional issues involved in referring patients to specialized palliative care.
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Affiliation(s)
- Aline Sarradon-Eck
- 1 Aix Marseille University, INSERM, IRD, SESSTIM, Economics and Social Science Applied to Health & Analysis of Medical Information, Marseille, France.,2 Institut Paoli-Calmettes, Cancer, Biomedicine & Society, Marseille, France
| | - Sylvain Besle
- 1 Aix Marseille University, INSERM, IRD, SESSTIM, Economics and Social Science Applied to Health & Analysis of Medical Information, Marseille, France.,3 Drug Development Department (DITEP), Gustave Roussy, University Paris-Sud, University Paris-Saclay, Villejuif, France
| | - Jaïs Troian
- 4 Aix-Marseille University, Psychologie, Marseille, France
| | - Géraldine Capodano
- 5 Institut Paoli-Calmettes, Département de Soins de Support et Palliatifs, Marseille, France
| | - Julien Mancini
- 6 Aix-Marseille University, APHM, INSERM, IRD, SESSTIM, Economics and Social Science Applied to Health and Analysis of Medical Information, Hop Timone, BioSTIC, Biostatistique et Technologies de l'Information et de la Communication, Marseille, France
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Palliative care in everyday practice of radiation oncologists : Results from a web-based survey among medical members of the German Society for Radiation Oncology (DEGRO). Strahlenther Onkol 2018; 195:659-667. [PMID: 30498845 DOI: 10.1007/s00066-018-1403-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/13/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE Little is known about the attitudes of radiation oncologists towards palliative care, about their competences in this field, and about the collaboration with palliative care specialists. Our aim was to close this gap and understand more about the importance of an additional qualification in palliative care. METHODS Medical members of the German Society for Radiation Oncology (DEGRO) were electronically surveyed during November-December 2016. RESULTS The survey was emailed successfully to 1110 addressees, whereas a total of 205 questionnaires were eligible for analysis (response rate 18.4%). 55 (26.8%) of the respondents had an additional qualification in palliative care. Physicians who had an additional qualification in palliative care (PC qualification) reported palliative care needs for their patients more frequently than the other respondents (89.0 vs. 82.7%, p = 0.008). Furthermore, they were most likely to report a high confidence in palliative care competences, such as "communication skills & support for relatives" (83.6 vs. 59.3%, p = 0.013), "symptom control," and "pain management" (94.5 vs. 67.7%, p < 0.001 and 90.9 vs. 73.3%, p = 0.008, respectively). Respondents with a PC qualification more often involved palliative care specialists than the other respondents (63.3 vs. 39.3%, p = 0.007). Perceived main barriers regarding palliative care in radiation oncology included time aspects (9.2%), stigmata (8.5%), and the lack of interdisciplinary collaboration (8.5%). CONCLUSIONS This analysis demonstrated that aspects of palliative care strongly impact on daily practice in radiation oncology. Additional qualifications and comprehensive training in palliative medicine may contribute to improved patient care in radiation oncology.
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Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol 2018; 19:e588-e653. [DOI: 10.1016/s1470-2045(18)30415-7] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/16/2018] [Accepted: 05/22/2018] [Indexed: 02/06/2023]
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Hui D, Hannon B, Zimmermann C, Bruera E. Improving patient and caregiver outcomes in oncology: Team-based, timely, and targeted palliative care. CA Cancer J Clin 2018; 68:356-376. [PMID: 30277572 PMCID: PMC6179926 DOI: 10.3322/caac.21490] [Citation(s) in RCA: 218] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Over the past decade, a large body of evidence has accumulated supporting the integration of palliative care into oncology practice for patients with advanced cancer. The question is no longer whether palliative care should be offered, but what is the optimal model of delivery, when is the ideal time to refer, who is in greatest need of a referral, and how much palliative care should oncologists themselves be providing. These questions are particularly relevant given the scarcity of palliative care resources internationally. In this state-of-the-science review directed at the practicing cancer clinician, the authors first discuss the contemporary literature examining the impact of specialist palliative care on various health outcomes. Then, conceptual models are provided to support team-based, timely, and targeted palliative care. Team-based palliative care allows the interdisciplinary members to address comprehensively the multidimensional care needs of patients and their caregivers. Timely palliative care, at its best, is preventive care to minimize crises at the end of life. Targeted palliative care involves identifying the patients most likely to benefit from specialist palliative care interventions, akin to the concept of targeted cancer therapies. Finally, the strengths and weaknesses of innovative care models, such as outpatient clinics, embedded clinics, nurse-led palliative care, primary palliative care provided by oncology teams, and automatic referral, are summarized. Moving forward, more research is needed to determine how different health systems can best personalize palliative care to provide the right level of intervention, for the right patient, in the right setting, at the right time. CA Cancer J Clin. 2018;680:00-00. 2018 American Cancer Society, Inc.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Makarem M, Mohammed S, Swami N, Pope A, Kevork N, Krzyzanowska M, Rodin G, Hannon B, Zimmermann C. Experiences and Expectations of Bereavement Contact among Caregivers of Patients with Advanced Cancer. J Palliat Med 2018; 21:1137-1144. [DOI: 10.1089/jpm.2017.0530] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Maisam Makarem
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Shan Mohammed
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Nadia Swami
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Ashley Pope
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Nanor Kevork
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Monika Krzyzanowska
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Breffni Hannon
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Rodin G, Lo C, Rydall A, Shnall J, Malfitano C, Chiu A, Panday T, Watt S, An E, Nissim R, Li M, Zimmermann C, Hales S. Managing Cancer and Living Meaningfully (CALM): A Randomized Controlled Trial of a Psychological Intervention for Patients With Advanced Cancer. J Clin Oncol 2018; 36:2422-2432. [PMID: 29958037 PMCID: PMC6085180 DOI: 10.1200/jco.2017.77.1097] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Purpose Individuals with advanced cancer experience substantial distress in response to disease burden and impending mortality. Managing Cancer And Living Meaningfully (CALM) is a novel, brief, manualized psychotherapeutic intervention intended to treat and prevent depression and end-of-life distress in patients with advanced cancer. We conducted a randomized controlled trial to compare CALM with usual care (UC) in this population. Methods Patients with advanced cancer were recruited from outpatient oncology clinics at a comprehensive cancer center into an unblinded randomized controlled trial. Permuted block randomization stratified by Patient Health Questionnaire-9 depression score allocated participants to CALM plus UC or to UC alone. Assessments of depressive symptoms (primary outcome), death-related distress, and other secondary outcomes were conducted at baseline, 3 months (primary end point), and 6 months (trial end point). Analyses were by intention to treat. Analysis of covariance was used to test for outcome differences between groups at follow-up, controlling for baseline. Mixed-model results are reported. Results Participants (n = 305) were recruited between February 3, 2012, and March 4, 2016, and randomly assigned to CALM (n = 151) or UC (n = 154). CALM participants reported less-severe depressive symptoms than UC participants at 3 months (Δ = 1.09; P = .04; Cohen's d = 0.23; 95% CI, 0.04 to 2.13) and at 6 months (Δ = 1.29; P = .02; d = 0.29; 95% CI, 0.24 to 2.35). Significant findings for greater end-of-life preparation at 6 months also favored CALM versus UC. No adverse effects were identified. Conclusion Findings suggest that CALM is an effective intervention that provides a systematic approach to alleviating depressive symptoms in patients with advanced cancer and addresses the predictable challenges these patients face.
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Affiliation(s)
- Gary Rodin
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Christopher Lo
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Anne Rydall
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Joanna Shnall
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Carmine Malfitano
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Aubrey Chiu
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Tania Panday
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Sarah Watt
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Ekaterina An
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Rinat Nissim
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Madeline Li
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Camilla Zimmermann
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
| | - Sarah Hales
- All authors: Princess Margaret Cancer Centre; Gary Rodin, Christopher Lo, Rinat Nissim, Madeline Li, Camilla Zimmermann, and Sarah Hales, University of Toronto; Toronto, Ontario, Canada
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Popovic G, Harhara T, Pope A, Al-Awamer A, Banerjee S, Bryson J, Mak E, Lau J, Hannon B, Swami N, Le LW, Zimmermann C. Patient-Reported Functional Status in Outpatients With Advanced Cancer: Correlation With Physician-Reported Scores and Survival. J Pain Symptom Manage 2018; 55:1500-1508. [PMID: 29496534 DOI: 10.1016/j.jpainsymman.2018.02.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/15/2018] [Accepted: 02/15/2018] [Indexed: 12/14/2022]
Abstract
CONTEXT Performance status measures are increasingly completed by patients in outpatient cancer settings, but are not well validated for this use. OBJECTIVES We assessed performance of a patient-reported functional status measure (PRFS, based on the Eastern Cooperative Oncology Group [ECOG]), compared with the physician-completed ECOG, in terms of agreement in ratings and prediction of survival. METHODS Patients and physicians independently completed five-point PRFS (lay version of ECOG) and ECOG measures on first consultation at an oncology palliative care clinic. We assessed agreement between PRFS and ECOG using weighted Kappa statistics, and used linear regression to determine factors associated with the difference between PRFS and ECOG ratings. We used the Kaplan-Meier method to estimate the patients' median survival, categorized by PRFS and ECOG, and assessed predictive accuracy of these measures using the C-statistic. RESULTS For the 949 patients, there was moderate agreement between PRFS and ECOG (weighted Kappa 0.32; 95% CI: 0.28-0.36). On average, patients' ratings of performance status were worse by 0.31 points (95% CI: 0.25-0.37, P < 0.0001); this tendency was greater for younger patients (P = 0.002) and those with worse symptoms (P < 0.0001). Both PRFS and ECOG scores correlated well with overall survival; the C-statistic was higher for the average of PRFS and ECOG scores (0.619) than when reported individually (0.596 and 0.604, respectively). CONCLUSION Patients tend to rate their performance status worse than physicians, particularly if they are younger or have greater symptom burden. Prognostic ability of performance status could be improved by using the average of patients and physician scores.
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Affiliation(s)
- Gordana Popovic
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Thana Harhara
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Ashley Pope
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ahmed Al-Awamer
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Subrata Banerjee
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Bryson
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ernie Mak
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jenny Lau
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nadia Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Lisa W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Princess Margaret Cancer Research Institute, University Health Network, Toronto, Ontario, Canada.
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Mohammed S, Swami N, Pope A, Rodin G, Hannon B, Nissim R, Hales S, Zimmermann C. “I didn't want to be in charge and yet I was”: Bereaved caregivers' accounts of providing home care for family members with advanced cancer. Psychooncology 2018; 27:1229-1236. [DOI: 10.1002/pon.4657] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 12/02/2017] [Accepted: 01/18/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Shan Mohammed
- Lawrence S. Bloomberg Faculty of Nursing; University of Toronto; Toronto Canada
- Department of Supportive Care, Princess Margaret Cancer Centre; University Health Network; Toronto Canada
| | - Nadia Swami
- Department of Supportive Care, Princess Margaret Cancer Centre; University Health Network; Toronto Canada
| | - Ashley Pope
- Department of Supportive Care, Princess Margaret Cancer Centre; University Health Network; Toronto Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre; University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
- Princess Margaret Cancer Research Institute; Toronto Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre; University Health Network; Toronto Canada
- Division of Medical Oncology; University of Toronto; Toronto Canada
| | - Rinat Nissim
- Department of Supportive Care, Princess Margaret Cancer Centre; University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
| | - Sarah Hales
- Department of Supportive Care, Princess Margaret Cancer Centre; University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre; University Health Network; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
- Princess Margaret Cancer Research Institute; Toronto Canada
- Division of Medical Oncology; University of Toronto; Toronto Canada
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McDonald J, Swami N, Pope A, Hales S, Nissim R, Rodin G, Hannon B, Zimmermann C. Caregiver quality of life in advanced cancer: Qualitative results from a trial of early palliative care. Palliat Med 2018; 32:69-78. [PMID: 29130418 DOI: 10.1177/0269216317739806] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early involvement of palliative care improves patient quality of life; however, quantitative studies have not yet demonstrated a similar effect for caregivers, for whom the construct of quality of life is less well developed. AIM To conceptualise quality of life of caregivers from their own perspective and to explore differences in themes between those who did or did not receive an early palliative care intervention. DESIGN Qualitative grounded theory study. SETTING Tertiary comprehensive cancer centre. PARTICIPANTS Following participation in a cluster-randomised trial of early palliative care, 23 caregivers (14 intervention and 9 control) of patients with advanced cancer participated in semi-structured interviews to discuss their quality of life. RESULTS The core category was 'living in the patient's world'. Five related themes were 'burden of illness and caregiving', 'assuming the caregiver role', 'renegotiating relationships', 'confronting mortality' and 'maintaining resilience'. There was thematic consistency between trial arms, except for the last two themes, which had distinct differences. Participants in the intervention group engaged in open discussion about the end of life, balanced hope with realism and had increased confidence from a range of professional supports. Controls tended to engage in 'deliberate ignorance' about the future, felt uncertain about how they would cope and lacked knowledge of available supports. CONCLUSIONS Caregiver quality of life is influenced profoundly by the interaction with the patient and should be measured with specific questionnaires that include content related to confronting mortality and professional supports. This would improve delineation of quality of life for caregivers and allow greater sensitivity to change. Registration: clinicaltrials.gov NCT01248624.
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Affiliation(s)
- Julie McDonald
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,2 Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nadia Swami
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ashley Pope
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Sarah Hales
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,3 Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Rinat Nissim
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,3 Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Gary Rodin
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,3 Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,4 The Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Breffni Hannon
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,2 Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Camilla Zimmermann
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,2 Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,3 Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,4 The Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Kang L, Liu XH, Zhang J, Shan PY, Wang JP, Zhong P, Du XH, Du YF, Yu BC, Wei N, Lou HL, Bian O, Chen HH, Lin F, Zhou HL, He W, Long HC, Hong LR, Su H, Yang JN, Jiang YL, Shi Y, Ning J, Liang F, Wang Z, Gong T, Zhu ML, Ning XH, Chen ZJ, Chen LK. Attitudes Toward Advance Directives Among Patients and Their Family Members in China. J Am Med Dir Assoc 2017; 18:808.e7-808.e11. [PMID: 28676293 DOI: 10.1016/j.jamda.2017.05.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 05/18/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Chinese people are generally unfamiliar with the concept of advance care planning or advance directives (ACP/ADs), which raises dilemmas in life-support choice and can even affect clinical decision making. To understand and address the issues involved better, we investigated the awareness of ACP/ADs in China, as well as people's attitudes toward medical autonomy and end-of-life care. DESIGN A multicenter cross-sectional survey, conducted from August 1 to December 31, 2016. SETTING Twenty-five hospitals located in 15 different provinces throughout mainland China. PARTICIPANTS Pairs of adult patients without dementia or malignancies, and a family member. MEASUREMENTS Participants self-filled anonymous questionnaires, and the data collected were analyzed to relate patients' sociodemographic characteristics to their awareness of ACP/ADs and attitudes to health care autonomy and end-of-life care. RESULTS Among 1084 patients who completed the questionnaire, 415 (38.3%) had heard about ACP/ADs. Having been informed about ACP/ADs, 995 (91.8%) were willing to find out their true health status and decide for themselves; 549 (50.6%) wanted to institute ACP/ADs. Regarding end-of-life care, 473 (43.6%) chose Do Not Resuscitate, and 435 (40.1%) wished to forgo life-support treatment if irreversibly moribund. Patients predominantly (481, 44.4%) chose general hospital as their preferred place to spend their last days of life; only 114 (10.5%) favored a special hospice facility. Patients' main concerns during end-of-life care were symptom control (35.1%), followed by functional maintenance and quality of life (29.8%), and prolonging life (18.9%). More highly educated patients had significantly greater awareness of ACP/ADs than less well educated ones (χ2 = 59.22, P < .001) and were more willing to find out the truth for themselves (χ2 = 58.30, P ≤ .001) and make medical decisions in advance (χ2 = 55.92, P < .001). Younger patients were also more willing than older ones to know the truth (χ2 = 38.23, P = .001) and make medical decisions in advance (χ2 = 18.42, P = .018), and were also more likely to wish to die at home (χ2 = 96.25, P < .001). Only 212 patients' family members (19.6%) wanted life-support treatment for themselves if irreversibly moribund, whereas 592 (54.6%) would want their relative to receive such procedures in the same circumstances; a similar discrepancy was evident for end-of-life invasive treatment (18.3% vs 42.7%). CONCLUSIONS Awareness about ACP/ADs in China is still low. Providing culturally sensitive knowledge, education, and communication regarding ACP/ADs is a feasible first step to promoting this sociomedical practice.
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Affiliation(s)
- Lin Kang
- Geriatrics Department, Peking Union Medical College Hospital, Beijing, China
| | - Xiao-Hong Liu
- Geriatrics Department, Peking Union Medical College Hospital, Beijing, China.
| | - Jing Zhang
- Geriatrics Department, Dalian Friendship Hospital, Dalian, China
| | - Pei-Yan Shan
- Geriatrics Department, Qilu Hospital, Shandong University, Jinan, China
| | - Jie-Ping Wang
- Geriatrics Department, Fuxing Hospital, Capital Medical University, Beijing, China
| | - Ping Zhong
- Geriatrics Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Xiao-Hong Du
- Geriatrics Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yu-Feng Du
- Geriatrics Department, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Bao-Cheng Yu
- Geriatrics Department, Bethune International Peace Hospital, Shijiazhuang, China
| | - Nan Wei
- VIP Ward, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hui-Ling Lou
- Geriatrics Department, Guang Zhou First People's Hospital, Guangzhou, China
| | - Ou Bian
- Department No.1 Cadre Ward, Shenyang Military Command General Hospital, China
| | - Huai-Hong Chen
- Geriatrics Department, Zhejiang Hospital, Hangzhou, China
| | - Fan Lin
- Geriatrics Department, Fujian Provincial Hospital, Fuzhou, China
| | - Hong-Lian Zhou
- Geriatrics Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Wen He
- Geriatrics Department, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Huai-Cong Long
- Geriatric Intensive Care Unit, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Lu-Rong Hong
- Geriatrics Department, Zhangzhou Municipal Hospital of Fujian Province, Zhangzhou, China
| | - Hui Su
- Geriatrics Department, Xijing Hospital, Fourth Military Medical University, Xian, China
| | - Jun-Nan Yang
- Geriatrics Department, Peking University Shougang Hospital, Beijing, China
| | - Yong-Liang Jiang
- Geriatrics Department, Hunan Provincial People's Hospital, Changsha, China
| | - Ye Shi
- Geriatrics Department, Shaanxi Provincial People's Hospital, Xian, China
| | - Jing Ning
- Geriatrics Department, Ninth People's Hospital, Zhengzhou, China
| | - Fang Liang
- Geriatrics Department No. 3, First Hospital of Shijiazhuang, Shijiazhuang, China
| | - Zhong Wang
- Geriatrics Department, Chengdu Fifth People's Hospital, Chengdu, China
| | - Ting Gong
- Cadre Ward Department, The PLA 401 Hospital, Qingdao, Shandong, China
| | - Ming-Lei Zhu
- Geriatrics Department, Peking Union Medical College Hospital, Beijing, China
| | - Xiao-Hong Ning
- Geriatrics Department, Peking Union Medical College Hospital, Beijing, China
| | - Zhi-Jun Chen
- Department of Healthcare Management, Yuanpei University of Medical Technology, Hsinchu, Taiwan
| | - Liang-Kung Chen
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Aging and Health Research Center, National Yang-Ming University, Taipei, Taiwan.
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Körner P, Ehrmann K, Hartmannsgruber J, Metz M, Steigerwald S, Flentje M, van Oorschot B. Patient-reported symptoms during radiotherapy : Clinically relevant symptom burden in patients treated with palliative and curative intent. Strahlenther Onkol 2017; 193:570-577. [PMID: 28573475 DOI: 10.1007/s00066-017-1146-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 04/27/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND The benefits of patient-reported symptom assessment combined with integrated palliative care are well documented. This study assessed the symptom burden of palliative and curative-intent radiation oncology patients. PATIENTS AND METHODS Prior to first consultation and at the end of RT, all adult cancer patients planned to receive fractionated percutaneous radiotherapy (RT) were asked to answer the Edmonton Symptom Assessment Scale (ESAS; nine symptoms from 0 = no symptoms to 10 = worst possible symptoms). Mean values were used for curative vs. palliative and pre-post comparisons, and the clinical relevance was evaluated (symptom values ≥ 4). RESULTS Of 163 participating patients, 151 patients (90.9%) completed both surveys (116 curative and 35 palliative patients). Before beginning RT, 88.6% of palliative and 72.3% of curative patients showed at least one clinically relevant symptom. Curative patients most frequently named decreased general wellbeing (38.6%), followed by tiredness (35.0%), anxiety (32.4%), depression (30.0%), pain (26.3%), lack of appetite (23.5%), dyspnea (17.8%), drowsiness (8.0%) and nausea (6.1%). Palliative patients most frequently named decreased general wellbeing (62.8%), followed by pain (62.8%), tiredness (60.0%), lack of appetite (40.0%), anxiety (38.0%), depression (33.3%), dyspnea (28.5%), drowsiness (25.7%) and nausea (14.2%). At the end of RT, the proportion of curative and palliative patients with a clinically relevant symptom had increased significantly to 79.8 and 91.4%, respectively; whereas the proportion of patients reporting clinically relevant pain had decreased significantly (42.8 vs. 62.8%, respectively). Palliative patients had significantly increased tiredness. Curative patients reported significant increases in pain, tiredness, nausea, drowsiness, lack of appetite and restrictions in general wellbeing. CONCLUSION Assessment of patient-reported symptoms was successfully realized in radiation oncology routine. Overall, both groups showed a high symptom burden. The results prove the need of systematic symptom assessment and programs for early integrated supportive and palliative care in radiation oncology.
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Affiliation(s)
- Philipp Körner
- Interdisziplinäres Zentrum Palliativmedizin, Universitätsklinikum Würzburg, Josef-Schneider-Str. 2, 97080, Würzburg, Germany. .,Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Würzburg, Würzburg, Germany.
| | - Katja Ehrmann
- Medizinische Psychologie und Psychotherapie, Medizinische Soziologie und Rehabilitationswissenschaften, Universitätsklinikum Würzburg, Würzburg, Germany
| | | | - Michaela Metz
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Sabrina Steigerwald
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Michael Flentje
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Birgitt van Oorschot
- Interdisziplinäres Zentrum Palliativmedizin, Universitätsklinikum Würzburg, Josef-Schneider-Str. 2, 97080, Würzburg, Germany
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McDonald J, Swami N, Hannon B, Lo C, Pope A, Oza A, Leighl N, Krzyzanowska MK, Rodin G, Le LW, Zimmermann C. Impact of early palliative care on caregivers of patients with advanced cancer: cluster randomised trial. Ann Oncol 2017; 28:163-168. [PMID: 27687308 DOI: 10.1093/annonc/mdw438] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Early palliative care improves the quality of life (QoL) and satisfaction with care of patients with advanced cancer, but little is known about its effect on caregivers. Here, we report outcomes of caregiver satisfaction with care and QoL from a trial of early palliative care. Patients and methods Twenty-four medical oncology clinics were cluster-randomised, stratified by tumour site (lung, gastrointestinal, genitourinary, breast and gynaecological), to early palliative care team referral, or to standard oncology care with palliative care only as needed. Caregivers of patients with advanced cancer (clinical prognosis of 6-24 months, Eastern Cooperative Oncology Group 0-2) in both trial arms completed validated measures assessing satisfaction with care (FAMCARE-19) and QoL [SF-36v2 Health Survey; Caregiver QoL-Cancer (CQoL-C)], at baseline and monthly for 4 months. We used a multilevel linear random-intercept mixed-effect model to test whether there was improvement in the intervention group relative to the control group over 3 and 4 months. Results A total of 182 caregivers completed baseline measures (94 intervention, 88 control); 151 caregivers (77 intervention, 74 control) completed at least one follow-up assessment. Satisfaction with care improved in the palliative intervention group compared with controls over 3 months (P = 0.007) and 4 months (P = 0.02). There was no significant improvement in the intervention group compared with controls for CQoL-C (3 months: P = 0.92, 4 months: P = 0.51), Physical Component Summary of the SF-36v2 Health Survey (3 months: P = 0.83, 4 months: P = 0.20), or Mental Component Summary of the SF-36v2 Health Survey (3 months: P = 0.87, 4 months: P = 0.60). Conclusion Early palliative care increased satisfaction with care in caregivers of patients with advanced cancer. ClinicalTrials.gov identifier NCT01248624.
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Affiliation(s)
- J McDonald
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada
| | - N Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - B Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada
| | - C Lo
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - A Pope
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - A Oza
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - N Leighl
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - M K Krzyzanowska
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - G Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Campbell Family Research Institute, Toronto, Canada
| | - L W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - C Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Campbell Family Research Institute, Toronto, Canada
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Otsuka M. Factors Associated with Length of Stay at Home in the Final Month of Life among Advanced Cancer Patients: A Retrospective Chart Review. J Palliat Med 2017; 20:884-889. [PMID: 28437210 DOI: 10.1089/jpm.2016.0455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Living at home is an important factor for maintaining high quality of life among patients. Many studies have discussed parameters associated with place of death, but no studies have yet clarified which factors influence the length of stay at home during the end of life. OBJECTIVE The aim of this study was to identify factors influencing the amount of time spent at home during the final month of life among patients with advanced cancer. METHODS A retrospective chart review was conducted for 415 patients with advanced cancer. Multivariate multiple linear regression analysis was used to examine relationships between the length of stay at home during the final month of life and variables measuring patient's background (four indicators), family structure (three indicators) cancer type (four types), chief complaint at initial palliative care referral (seven indicators), and medical interventions (three factors). RESULTS The multiple linear regression predicting time spent at home in the last month of life yielded partial regression coefficients of 4.2 for past outpatient palliative care services (OPCS) (p < 0.001) and 3.3 for in-home nurse visits (p = 0.003). DISCUSSION The most influential factor for length of stay at home in the final month of life was a history of OPCS. Many patients with advanced cancer who receive chemotherapy without OPCS spend time as inpatients after an initial period at home. Palliative care interventions for outpatients effectively enable patients with advanced cancer to adapt and continue living at home.
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Affiliation(s)
- Masatomo Otsuka
- Department of Palliative Care, Kindai University Sakai Hospital , Osaka, Japan
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45
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Hannon B, Swami N, Rodin G, Pope A, Zimmermann C. Experiences of patients and caregivers with early palliative care: A qualitative study. Palliat Med 2017; 31:72-81. [PMID: 27495814 DOI: 10.1177/0269216316649126] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Early palliative care improves quality of life and satisfaction with care and is increasingly endorsed for patients with advanced cancer. However, little is known about the experience of receiving early palliative care from a patient and caregiver perspective. AIM The aim of this qualitative study was to determine, from a participant perspective, the experience of receiving early palliative care and elements of that care. DESIGN Qualitative grounded theory study using individual interviews. SETTING/PARTICIPANTS The study took place at a comprehensive cancer centre. Patients ( n = 26) and caregivers ( n = 14) from the intervention arm of a cluster-randomised controlled trial of early palliative care versus standard oncology care participated in qualitative interviews. Participants were asked to comment on their quality of life, the quality of care provided over the intervention period and their experiences with the palliative care team. RESULTS Participants described feeling supported and guided in their illness experience and in their navigation of the healthcare system. Specific elements of early palliative care included prompt, personalised symptom management; holistic support for patients and caregivers; guidance in decision-making; and preparation for the future. Patients with symptoms particularly valued prompt attention to their physical concerns, while those without symptoms valued other elements of care. Although three patients were ambivalent about their current need for palliative care, no distress was reported as a consequence of the intervention. CONCLUSION The elements of care described by participants may be used to develop, support and refine models of early palliative care for patients with cancer.
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Affiliation(s)
- Breffni Hannon
- 1 Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,2 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Nadia Swami
- 2 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Gary Rodin
- 2 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,3 Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,4 Campbell Family Cancer Research Institute, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ashley Pope
- 2 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Camilla Zimmermann
- 1 Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,2 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,3 Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,4 Campbell Family Cancer Research Institute, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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46
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Wentlandt K, Dall'Osto A, Freeman N, Le LW, Kaya E, Ross H, Singer LG, Abbey S, Clarke H, Zimmermann C. The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program. Clin Transplant 2016; 30:1591-1596. [PMID: 27910190 DOI: 10.1111/ctr.12838] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 12/20/2022]
Abstract
Although patients within a transplant program are awaiting or have received disease modifying or curative treatment, they are also facing advanced illness and the possibility of death. The involvement of specialized palliative care services for these patients may improve symptom management and facilitate advance care planning. However, patients in organ transplantation programs have difficulty accessing palliative care resources and often do so only sporadically in the inpatient setting. Currently, there is little access to ambulatory palliative care for these patients and there have been no descriptions of programs delivering such care in the medical literature. We outline the development and structure of a Transplant Palliative Care Clinic within the University Health Network's Multi-Organ Transplant Program, in Toronto, Canada. This information may be helpful for others aiming to provide early, integrated palliative care to patients awaiting and receiving organ transplantation.
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Affiliation(s)
- Kirsten Wentlandt
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Angela Dall'Osto
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Nicole Freeman
- Department of Family Medicine [Windsor Program], Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Lisa W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ebru Kaya
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Heather Ross
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada
| | - Lianne G Singer
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Susan Abbey
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Hance Clarke
- Pain Research Unit and the Transitional Pain Service, Department of Anaesthesia, University Health Network, Toronto, ON, Canada.,Department of Anaesthesia, University of Toronto, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Campbell Family Cancer Research Institute, Ontario Cancer Institute, Toronto, ON, Canada
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47
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McDonald JC, du Manoir JM, Kevork N, Le LW, Zimmermann C. Advance directives in patients with advanced cancer receiving active treatment: attitudes, prevalence, and barriers. Support Care Cancer 2016; 25:523-531. [DOI: 10.1007/s00520-016-3433-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/26/2016] [Indexed: 11/25/2022]
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Tong E, Deckert A, Gani N, Nissim R, Rydall A, Hales S, Rodin G, Lo C. The meaning of self-reported death anxiety in advanced cancer. Palliat Med 2016; 30:772-9. [PMID: 26857360 DOI: 10.1177/0269216316628780] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Death anxiety is important but understudied in palliative care. New self-report measurements have been developed, but their interpretation and clinical utility may not be evident. AIM To inform our understanding of death anxiety in patients with advanced cancer by exploring the relationship between this self-reported symptom and its clinical presentation. DESIGN Participants were part of a psychotherapy trial in advanced cancer. First therapy session transcripts were analyzed using interpretive description in patients reporting low, moderate, and high death anxiety on the Death and Dying Distress Scale (DADDS). SETTING/PARTICIPANTS A total of 16 participants (10 women and 6 men) with advanced or metastatic cancer were sampled from the Princess Margaret Cancer Centre, Toronto, Canada. Six participants reported low death anxiety scores (Death and Dying Distress Scale: 0-19), five moderate (Death and Dying Distress Scale: 20-50), and five high (Death and Dying Distress Scale: 51-75). RESULTS The low death anxiety group exhibited psychological readiness for death, or contrastingly, non-reflectiveness about death. The moderate group recognized the imminence of mortality, which impacted treatment decisions and future plans. Prior experience with death was discussed as raising the salience of mortality. The high group felt dominated by powerful emotions and could not make sense of their situation. Their distress was exacerbated by substantial relational concerns. CONCLUSION Self-reported death anxiety is affected by the awareness and ability to reflect on mortality. Death and Dying Distress Scale scores may facilitate exploration of this symptom as part of a clinical assessment and may serve to guide treatment approaches. Greater attention to death anxiety is consistent with and recommended by contemporary approaches to palliative care.
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Affiliation(s)
- Eryn Tong
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Amy Deckert
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Nina Gani
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany
| | - Rinat Nissim
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Anne Rydall
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Sarah Hales
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Chris Lo
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada Department of Psychiatry, University of Toronto, Toronto, ON, Canada Department of Psychology, University of Guelph-Humber, Toronto, ON, Canada
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Salins N, Ramanjulu R, Patra L, Deodhar J, Muckaden MA. Integration of Early Specialist Palliative Care in Cancer Care and Patient Related Outcomes: A Critical Review of Evidence. Indian J Palliat Care 2016; 22:252-7. [PMID: 27559252 PMCID: PMC4973484 DOI: 10.4103/0973-1075.185028] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Introduction: World Health Organization and American Society of Clinical Oncology recommend early integration of specialist palliative care in patients with cancer. This paper focuses on critical review of evidence on integration of early specialist palliative care in cancer care and patient-related outcomes. Methods: The question for the literature search was – Does integration of early specialist palliative care in cancer care influences patient-related outcomes? 31 articles related to literature search review question were included in this paper. Results: Ten patient-related outcomes of early specialist palliative care in adult cancer care was studied. Studies by Temel et al. (2012), Bakitas et al. (2009), Zimmermann et al. (2014), Rugno et al. (2014), Lowery et al. (2013) and Walker et al. (2014) showed early specialist palliative care improves health-related quality of life (HRQOL). Studies by Pirl et al. (2012), Lowery et al. (2013), and Walker et al. (2014) showed early specialist palliative care improved mood depression and anxiety. Studies by Zimmermann et al. and Rugno et al. (2014) showed symptom control benefit of early specialist palliative care. Studies by Temel (2010), Bakitas (2015) and Rugno et al. (2014) showed survival improvement with early specialist palliative care. All these studies were carried in ambulatory palliative care setting. No survival benefit of palliative care intervention was seen in inpatient palliative care setting. The studies by Geer et al. (2012), Rugno et al. (2014), and Lowery et al. (2013) showed that early palliative care intervention positively influences treatment decision making. All the studies showed that palliative care intervention group received less intravenous chemotherapy in last few weeks of life. Studies by Yoong et al. and Temel et al. (2011) shows early specialist palliative care improves advanced care planning. Studies by Temel et al. (2010), Greer et al. (2012), McNamara et al. (2013), Hui et al. (2014), and Kwon et al.(2013) showed that early specialist palliative care improves health care utilization, planned discharge, less emergency room visits, and better hospice utilization. Studies by Wiese et al. (2013), Hui et al. (2014) and Temel et al. (2010) showed that early specialist palliative care improves end-of-life care outcomes. Study by Rugno et al. (2014) showed that early specialist palliative care improves health-related communication. Studies by Wallen et al. (2012) and Zimmermann et al. (2014) shows early specialist palliative care improves patient and family satisfaction. There is a lack of robust evidence at present to support role of early specialist palliative care interventions in pediatric and geriatric oncology. Qualitative studies have demonstrated few negative outcomes of early specialist palliative care intervention. Conclusions: In adult oncology, there is evidence to suggest early specialist palliative care improves HRQOL, mood, treatment decision-making, health care utilization, advanced care planning, patient satisfaction, and end-of-life care. There is moderate evidence to support the role of early specialist palliative care intervention in improvement of symptoms, survival, and health-related communication. There is limited evidence at present to support role of early specialist palliative care interventions in pediatric and geriatric oncology. Qualitative studies on barriers and negative patient outcomes may provide useful insights toward restructuring early specialist palliative care interventions.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Raghavendra Ramanjulu
- Integrative Oncology, HCG Bangalore Institute of Oncology, Bangalore, Karnataka, India
| | - Lipika Patra
- Palliative Care Specialist, Karunashraya Hospice, Bangalore, Karnataka, India
| | - Jayita Deodhar
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Mary Ann Muckaden
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
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Zimmermann C, Swami N, Krzyzanowska M, Leighl N, Rydall A, Rodin G, Tannock I, Hannon B. Perceptions of palliative care among patients with advanced cancer and their caregivers. CMAJ 2016; 188:E217-E227. [PMID: 27091801 PMCID: PMC4938707 DOI: 10.1503/cmaj.151171] [Citation(s) in RCA: 228] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Early palliative care is increasingly recommended but seldom practised. We sought to examine perceptions of palliative care among patients with advanced cancer and their caregivers. METHODS After conducting a cluster randomized controlled trial of early palliative care versus standard care for patients with advanced cancer, we approached patients and their caregivers to participate in semistructured interviews seeking to assess, qualitatively, their attitudes and perceptions about palliative care. We used the grounded theory method for data collection and analysis. RESULTS A total of 48 patients (26 intervention, 22 control) and 23 caregivers (14 intervention, 9 control) completed interviews. Participants' initial perceptions of palliative care in both trial arms were of death, hopelessness, dependency and end-of-life comfort care for inpatients. These perceptions provoked fear and avoidance, and often originated from interactions with health care professionals. During the trial, those in the intervention arm developed a broader concept of palliative care as "ongoing care" that improved their "quality of living" but still felt that the term itself carried a stigma. Participants in the intervention group emphasized the need for palliative care to be reframed and better explained by health care professionals. Participants in the control group generally considered it pointless to rename palliative care, but many in the intervention group stated emphatically that a different name was necessary in the early outpatient setting. INTERPRETATION There is a strong stigma attached to palliative care, which may persist even after positive experiences with an early palliative care intervention. Education of the public, patients and health care providers is paramount if early integration of palliative care is to be successful.
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Affiliation(s)
- Camilla Zimmermann
- Division of Medical Oncology (Zimmermann, Krzyzanowska, Leighl, Tannock, Hannon), Department of Medicine, Department of Psychiatry (Zimmermann, Rodin), University of Toronto; Department of Supportive Care (Zimmermann, Swami, Rydall, Rodin, Hannon), Department of Medical Oncology (Krzyzanowska, Tannock), The Campbell Family Cancer Research Institute (Zimmermann, Rodin, Tannock), Princess Margaret Cancer Centre, University Health Network, Toronto, Ont.
| | - Nadia Swami
- Division of Medical Oncology (Zimmermann, Krzyzanowska, Leighl, Tannock, Hannon), Department of Medicine, Department of Psychiatry (Zimmermann, Rodin), University of Toronto; Department of Supportive Care (Zimmermann, Swami, Rydall, Rodin, Hannon), Department of Medical Oncology (Krzyzanowska, Tannock), The Campbell Family Cancer Research Institute (Zimmermann, Rodin, Tannock), Princess Margaret Cancer Centre, University Health Network, Toronto, Ont
| | - Monika Krzyzanowska
- Division of Medical Oncology (Zimmermann, Krzyzanowska, Leighl, Tannock, Hannon), Department of Medicine, Department of Psychiatry (Zimmermann, Rodin), University of Toronto; Department of Supportive Care (Zimmermann, Swami, Rydall, Rodin, Hannon), Department of Medical Oncology (Krzyzanowska, Tannock), The Campbell Family Cancer Research Institute (Zimmermann, Rodin, Tannock), Princess Margaret Cancer Centre, University Health Network, Toronto, Ont
| | - Natasha Leighl
- Division of Medical Oncology (Zimmermann, Krzyzanowska, Leighl, Tannock, Hannon), Department of Medicine, Department of Psychiatry (Zimmermann, Rodin), University of Toronto; Department of Supportive Care (Zimmermann, Swami, Rydall, Rodin, Hannon), Department of Medical Oncology (Krzyzanowska, Tannock), The Campbell Family Cancer Research Institute (Zimmermann, Rodin, Tannock), Princess Margaret Cancer Centre, University Health Network, Toronto, Ont
| | - Anne Rydall
- Division of Medical Oncology (Zimmermann, Krzyzanowska, Leighl, Tannock, Hannon), Department of Medicine, Department of Psychiatry (Zimmermann, Rodin), University of Toronto; Department of Supportive Care (Zimmermann, Swami, Rydall, Rodin, Hannon), Department of Medical Oncology (Krzyzanowska, Tannock), The Campbell Family Cancer Research Institute (Zimmermann, Rodin, Tannock), Princess Margaret Cancer Centre, University Health Network, Toronto, Ont
| | - Gary Rodin
- Division of Medical Oncology (Zimmermann, Krzyzanowska, Leighl, Tannock, Hannon), Department of Medicine, Department of Psychiatry (Zimmermann, Rodin), University of Toronto; Department of Supportive Care (Zimmermann, Swami, Rydall, Rodin, Hannon), Department of Medical Oncology (Krzyzanowska, Tannock), The Campbell Family Cancer Research Institute (Zimmermann, Rodin, Tannock), Princess Margaret Cancer Centre, University Health Network, Toronto, Ont
| | - Ian Tannock
- Division of Medical Oncology (Zimmermann, Krzyzanowska, Leighl, Tannock, Hannon), Department of Medicine, Department of Psychiatry (Zimmermann, Rodin), University of Toronto; Department of Supportive Care (Zimmermann, Swami, Rydall, Rodin, Hannon), Department of Medical Oncology (Krzyzanowska, Tannock), The Campbell Family Cancer Research Institute (Zimmermann, Rodin, Tannock), Princess Margaret Cancer Centre, University Health Network, Toronto, Ont
| | - Breffni Hannon
- Division of Medical Oncology (Zimmermann, Krzyzanowska, Leighl, Tannock, Hannon), Department of Medicine, Department of Psychiatry (Zimmermann, Rodin), University of Toronto; Department of Supportive Care (Zimmermann, Swami, Rydall, Rodin, Hannon), Department of Medical Oncology (Krzyzanowska, Tannock), The Campbell Family Cancer Research Institute (Zimmermann, Rodin, Tannock), Princess Margaret Cancer Centre, University Health Network, Toronto, Ont
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