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Doherty C, Feder S, Gillespie-Heyman S, Akgün KM. Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU. J Intensive Care Med 2024; 39:715-732. [PMID: 37822226 DOI: 10.1177/08850666231204305] [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] [Indexed: 10/13/2023]
Abstract
Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.
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Affiliation(s)
- Christine Doherty
- Department of Internal Medicine New Haven, Yale New Haven Hospital, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, Orange, CT, USA
| | | | - Kathleen M Akgün
- Yale School of Medicine, New Haven, CT, USA
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA-Connecticut and Yale University School of Medicine, New Haven, CT, USA
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Kim S, Chervu N, Premji A, Mallick S, Verma A, Ali K, Benharash P, Donahue T. Association of Inpatient Palliative Care Consultation with Clinical and Financial Outcomes for Pancreatic Cancer. Ann Surg Oncol 2024; 31:1328-1335. [PMID: 37957512 DOI: 10.1245/s10434-023-14528-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/14/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Palliative care consultation (PCC) has been shown to improve quality of life and reduce costs for various chronic life-threatening diseases. Despite PCC incorporation into modern pancreatic cancer care guidelines, limited data regarding its specific utilization and impact on resource use is available. METHODS The 2016-2020 Nationwide Readmissions Database was used to identify all adult hospitalizations entailing pancreatic cancer. Only patients with at least one readmission within 90 days were included to account for uncaptured out-of-hospital mortality. Multivariable regression models were used to ascertain the relationship between inpatient PCC during initial hospitalization and index as well as cumulative costs, overall length of stay (LOS), readmission rate, and number of repeat hospitalizations. RESULTS Of an estimated 175,805 patients with pancreatic cancer, 11.1% had inpatient PCC during the index admission. PCC utilization significantly increased from 10.5% in 2016 to 11.6% in 2020 (nptrend < 0.001). After adjustment, PCC was associated with reduced index hospitalization costs [β: - $1100; 95% confidence interval (CI) - 1500, - 800; P < 0.001] and cumulative 90-day costs (β: - $11,700; 95% CI - 12,700, - 10,000; P < 0.001). PCC was associated with longer index LOS (β: + 1.12 days, 95% CI 0.92-1.31, P < 0.001) but significantly reduced cumulative LOS (β: - 3.16 days; 95% CI - 3.67, - 2.65; P < 0.001). Finally, PCC was linked with decreased odds of 30-day nonelective readmission (AOR: 0.48, 95% CI 0.45-0.50, P < 0.001). DISCUSSION PCC was associated with decreased costs, readmission rates, and number of hospitalizations among patients with pancreatic cancer. Directed strategies to increase utilization and reduce barriers to consultation should be implemented to encourage practitioners to maximize inpatient PCC referral rates.
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Affiliation(s)
- Shineui Kim
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Alykhan Premji
- Division of Surgical Oncology, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Timothy Donahue
- Division of Surgical Oncology, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA.
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Abedini NC, Downey L, Engelberg RA, Curtis JR, Sharma RK. End-of-life healthcare utilization and palliative care use among older adults with limited English proficiency. J Am Geriatr Soc 2022; 70:2847-2857. [PMID: 35670104 DOI: 10.1111/jgs.17913] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known about end-of-life healthcare utilization and palliative care use among older adults with serious illness and limited English proficiency (LEP). METHODS We conducted a retrospective analysis of seriously-ill older adults (65+) with and without LEP, from a large health system, who died between 2010 and 2018. Primary outcomes were measures of healthcare utilization in the last 30 and 180 days of life: hospitalization, emergency department (ED) visits, intensive care unit (ICU) admission, and 30-day readmission. Secondary outcomes were palliative care consultation and advance care planning documents. We used multivariate analyses adjusted for sociodemographic factors including race and ethnicity. RESULTS Among 18,490 decedents, 1363 had LEP. Patients with LEP were older at time of death (median age 80 vs 77 years), more likely to be female (48% vs 44%), of Asian descent (64% vs 4%), of Hispanic ethnicity (10% vs 2%), with <12th grade education (38% vs 9%), and Medicaid (36% vs 6%). In the last 30 days of life, patients with LEP had higher odds of ED visits (33% vs 20%; aOR 1.41, 95% CI 1.26-1.72; p < 0.001), readmission (12% vs 8%; aOR 1.64, 95% CI 1.30-2.07; p < 0.001), and in-hospital death (45% vs 37%; aOR 1.24, 95% CI 1.07-1.44; p = 0.005) compared to patients without LEP. Findings were similar in the last 180-days of life. Only 14% of patients with LEP and 10% of those without LEP received palliative care consultation in the last month of life. Patients with LEP were less likely to have advance care planning documents than patients without LEP (36% vs 40%; aOR 0.68, 95% CI 0.50-0.80; p < 0.001). CONCLUSIONS Older adults with serious illness and LEP have higher rates of end-of-life healthcare utilization. Additional research is needed to identify drivers of these differences and inform linguistically- and culturally-appropriate interventions to improve end-of-life care in this population.
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Affiliation(s)
- Nauzley C Abedini
- Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
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Kazazian K, Ng D, Swallow CJ. Impact of the coronavirus disease 2019 pandemic on delivery of and models for supportive and palliative care for oncology patients. Curr Opin Support Palliat Care 2022; 16:130-137. [PMID: 35862890 PMCID: PMC9451606 DOI: 10.1097/spc.0000000000000606] [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] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Supportive and palliative care services have been an important component of the overall COVID-19 pandemic response. However, significant changes in the provision and models of care were needed in order to optimize the care delivered to vulnerable cancer patients. This review discusses the evolution of palliative and supportive care service in response to the pandemic, and highlights remaining challenges. RECENT FINDINGS Direct competition for resources, as well as widespread implementation of safety measures resulted in major shifts in the mode of assessment and communication with cancer patients by supportive care teams. Telemedicine/virtual consultation and follow-up visits became an integral strategy, with high uptake and satisfaction amongst patients, families and providers. However, inequities in access to the required technologies were sometimes exposed. Hospice/palliative care unit (PCU) bed occupancy declined markedly because of restrictive visitation policies. Collection of patient-reported outcome (PRO) data was suspended in many cancer centers, with resulting under-recognition of anxiety and depression in ambulatory patients. As in many other areas, disparities in delivery of supportive and palliative care were magnified by the pandemic. SUMMARY Virtual care platforms have been widely adopted and will continue to be used to include a wider circle of family/friends and care providers in the provision of palliative and supportive care. To facilitate equitable delivery of supportive care within a pandemic, further research and resources are needed to train and support generalists and palliative care providers. Strategies to successfully collect PROs from all patients in a virtual manner must be developed and implemented.
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Affiliation(s)
- Karineh Kazazian
- Department of Surgical Oncology, Princess Margaret Hospital, University Health Network and Mount Sinai Hospital
- Division of General Surgery, Mount Sinai Hospital, Sinai Health System
- Department of Surgery, University of Toronto
| | - Deanna Ng
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Carol J. Swallow
- Department of Surgical Oncology, Princess Margaret Hospital, University Health Network and Mount Sinai Hospital
- Division of General Surgery, Mount Sinai Hospital, Sinai Health System
- Department of Surgery, University of Toronto
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
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Sullivan SS, Bo W, Li CS, Xu W, Chang YP. Predicting Hospice Transitions in Dementia Caregiving Dyads: An Exploratory Machine Learning Approach. Innov Aging 2022; 6:igac051. [PMID: 36452051 PMCID: PMC9701063 DOI: 10.1093/geroni/igac051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Indexed: 10/19/2023] Open
Abstract
Background and Objectives Hospice programs assist people with serious illness and their caregivers with aging in place, avoiding unnecessary hospitalizations, and remaining at home through the end-of-life. While evidence is emerging of the myriad of factors influencing end-of-life care transitions among persons living with dementia, current research is primarily cross- sectional and does not account for the effect that changes over time have on hospice care uptake, access, and equity within dyads. Research Design and Methods Secondary data analysis linking the National Health and Aging Trends Study to the National Study of Caregiving investigating important social determinants of health and quality-of-life factors of persons living with dementia and their primary caregivers (n = 117) on hospice utilization over 3 years (2015-2018). We employ cutting-edge machine learning approaches (correlation matrix analysis, principal component analysis, random forest [RF], and information gain ratio [IGR]). Results IGR indicators of hospice use include persons living with dementia having diabetes, a regular physician, a good memory rating, not relying on food stamps, not having chewing or swallowing problems, and whether health prevents them from enjoying life (accuracy = 0.685; sensitivity = 0.824; specificity = 0.537; area under the curve (AUC) = 0.743). RF indicates primary caregivers' age, and the person living with dementia's income, census division, number of days help provided by caregiver per month, and whether health prevents them from enjoying life predicts hospice use (accuracy = 0.624; sensitivity = 0.713; specificity = 0.557; AUC = 0.703). Discussion and Implications Our exploratory models create a starting point for the future development of precision health approaches that may be integrated into learning health systems that prompt providers with actionable information about who may benefit from discussions around serious illness goals-for-care. Future work is necessary to investigate those not considered in this study-that is, persons living with dementia who do not use hospice care so additional insights can be gathered around barriers to care.
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Affiliation(s)
| | - Wei Bo
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Chin-Shang Li
- School of Nursing, University at Buffalo, Buffalo, New York, USA
| | - Wenyao Xu
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Yu-Ping Chang
- School of Nursing, University at Buffalo, Buffalo, New York, USA
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Alhamdoun A, Al Qadire M, Aldiabat KM, Al-Rawajfah O. Nursing students' knowledge of palliative care: a short literature review. Int J Palliat Nurs 2021; 27:54-57. [DOI: 10.12968/ijpn.2021.27.1.54] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: Health professionals must be knowledgeable and skilled in providing palliative care. This short report reviews the literature that has assessed student nurses' knowledge of palliative care. Method: The following databases were searched: CINHAL, ScienceDirect, Medline, PubMed and Google Scholar for manuscripts published from 2014 to 2020. Only six articles met the inclusion criteria and were thoroughly reviewed. Findings: Students were found to have a poor knowledge of palliative care, especially the management of a patient's symptoms and the definition of palliative care. Conclusion: Integrating palliative care education within nursing curricula is a priority, although the best method to accomplish this is yet to be established.
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Affiliation(s)
| | - Mohammad Al Qadire
- College of Nursing, Sultan Qaboos University, Faculty of Nursing, Al Al-Bayt University
| | - Khaldoun M Aldiabat
- Assistant Professor, Community and Mental Health Department, College of Nursing, Sultant Qaboos University
| | - Omar Al-Rawajfah
- Associate Professor of Acute Care Nursing, Dean, College of Nursing, Sultan Qaboos University, Faculty of Nursing, Al Al-Bayt University
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Konrad C, Lossnitzer N, Boehlen FH, Haefeli WE, Holleczek B, Brenner H, Schoettker B, Wild B. Coping resources of heart failure patients - a comparison with cancer patients and individuals having no chronic condition results from the esther study. Heart Lung 2020; 49:829-835. [PMID: 33011461 DOI: 10.1016/j.hrtlng.2020.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Heart failure (HF) and cancer patients share similarities in symptom burden and depression prevalence. Coping resources, such as optimism have been associated with improved health-related quality of life (HRQoL) and mental health. OBJECTIVES To investigate a wide range of resources in a large population-based sample of HF patients; to compare resources between three groups: HF patients, cancer patients, and individuals having no chronic condition. METHODS This cross-sectional analysis was performed among n = 2761 subjects who participated in home visits during the 11-year follow-up of the epidemiological ESTHER study. Resources were assessed by trained medical doctors through a questionnaire that lists 26 items. One-way analyses of covariance (ANCOVAs) controlled for sociodemographic variables and depression were performed to compare resources between groups. RESULTS Family and self-efficacy were the most frequently reported resources in all groups. HF patients reported optimism significantly less frequently as a resource in comparison to cancer patients (p=.031). HF patients showed significantly lower levels of resource factor 3 (positive attitude), compared to cancer patients (p=.006), and not chronically ill participants (p=.037). CONCLUSIONS Family and self-efficacy seem to be the most important resources, regardless of diagnosis. HF patients appear to have significantly lower levels of resources concerning positive attitude, compared to cancer patients, and not chronically ill individuals. We suggest the development of psychosocial interventions to enhance optimism in HF.
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Affiliation(s)
- Cinara Konrad
- Heidelberg University Hospital, Department of General Internal Medicine and Psychosomatics, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany.
| | - Nicole Lossnitzer
- Heidelberg University Hospital, Department of General Internal Medicine and Psychosomatics, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Friederike H Boehlen
- Heidelberg University Hospital, Department of General Internal Medicine and Psychosomatics, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Germany
| | - Bernd Holleczek
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; Saarland Cancer Registry, Saarbruecken, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Ben Schoettker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; Network Aging Research, University of Heidelberg, Germany
| | - Beate Wild
- Heidelberg University Hospital, Department of General Internal Medicine and Psychosomatics, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
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