1
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Recchia A, Rizzi B, Favero A, Nobili A, Pasina L. Prevalence of Delirium in End-of-Life Palliative Care Patients: An Observational Study. Med Princ Pract 2022; 31:118-124. [PMID: 35038708 PMCID: PMC9209975 DOI: 10.1159/000521994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 12/28/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the prevalence of delirium, using the Assessment Test for Delirium and Cognitive Impairment (4AT) in end-of-life palliative care patients. SUBJECTS AND METHODS This retrospective cross-sectional study was conducted on end-of-life patients in a hospice or at home. All patients were evaluated with the 4AT for the presence of delirium. RESULTS Of the 461 patients analyzed, 76 (16.5%) were inpatients and 83.5% (385) outpatients. The median age was 79.5 (72-86) years, and 51.0% were female. According to the 4AT score, 126 patients (27.3%) had delirium (A4T ≥4) at admission, 28 (36.8%) were inpatients, and 98 (25.5%) outpatients. Around 33.8% of the cancer inpatients had delirium, while 20.6% of the cancer outpatients had delirium. The prevalence of delirium varied according to the setting, clinical condition, and life expectancy. In addition, 55.0% (11) actively dying inpatients, within 3 days, had delirium, and 56.7% (17) outpatients had delirium; while among those with life expectancy longer than 4 days, 30.4% (17) inpatients and 22.8% (81) outpatients were with delirium. CONCLUSIONS Our study confirms that delirium is common in cancer and noncancer palliative care patients. Further research on delirium in end-of-life palliative care patients should consider the complexity of palliative care of this population as well as of the characteristics of the settings.
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Affiliation(s)
| | | | | | - Alessandro Nobili
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Luca Pasina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
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2
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Featherstone I, Hosie A, Siddiqi N, Grassau P, Bush SH, Taylor J, Sheldon T, Johnson MJ. The experience of delirium in palliative care settings for patients, family, clinicians and volunteers: A qualitative systematic review and thematic synthesis. Palliat Med 2021; 35:988-1004. [PMID: 33784915 PMCID: PMC8189008 DOI: 10.1177/02692163211006313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Delirium is common in palliative care settings and is distressing for patients, their families and clinicians. To develop effective interventions, we need first to understand current delirium care in this setting. AIM To understand patient, family, clinicians' and volunteers' experience of delirium and its care in palliative care contexts. DESIGN Qualitative systematic review and thematic synthesis (PROSPERO 2018 CRD42018102417). DATA SOURCES The following databases were searched: CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, MEDLINE and PsycINFO (2000-2020) for qualitative studies exploring experiences of delirium or its care in specialist palliative care services. Study selection and quality appraisal were independently conducted by two reviewers. RESULTS A total of 21 papers describing 16 studies were included. In quality appraisal, trustworthiness (rigour of methods used) was assessed as high (n = 5), medium (n = 8) or low (n = 3). Three major themes were identified: interpretations of delirium and their influence on care; clinicians' responses to the suffering of patients with delirium and the roles of the family in delirium care. Nursing staff and other clinicians had limited understanding of delirium as a medical condition with potentially modifiable causes. Practice focused on alleviating patient suffering through person-centred approaches, which could be challenging with delirious patients, and medication use. Treatment decisions were also influenced by the distress of family and clinicians and resource limitations. Family played vital roles in delirium care. CONCLUSIONS Increased understanding of non-pharmacological approaches to delirium prevention and management, as well as support for clinicians and families, are important to enable patients' multi-dimensional needs to be met.
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Affiliation(s)
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent’s Health Network, Sydney, NSW, Australia
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Pamela Grassau
- School of Social Work, Carleton University, Ottawa, ON, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Palliative Care, Bruyere Continuing Care, Ottawa, ON, Canada
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Trevor Sheldon
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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3
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Soroka JT, Fling KJ, Heibel JM, Kutcher GR, Ward SJ. Terminal Delirium in Hospice: The Experiences and Perspectives of Caregivers Providing Care to Terminally Ill Patients in Home Settings. Am J Hosp Palliat Care 2021; 39:27-33. [PMID: 33685252 DOI: 10.1177/10499091211000729] [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] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Little is known about the experiences of caregivers who provide care to persons with terminal delirium (TD) in home settings. This scarcity of information is suggestive that further research is needed about care for hospice patients with delirium in the home and community. AIM To elicit views, feelings, and end-of-life care experiences of primary caregivers assisting dying persons with TD in hospice at home. DESIGN Qualitative, exploratory, cross-sectional study design was chosen. In-depth semistructured interviews explored caregiver experiences in caring for persons with TD. Qualitative thematic framework analysis was used. PARTICIPANTS Fifteen bereaved adult primary caregivers who received services from a hospice care program affiliated with a large nonprofit health system in the US Midwest. RESULTS Caregiver experiences were broad and reflected 4 major themes: symptomology, coping, effective and noneffective interventions, and support. The most distressing factors for caregivers were behaviors and symptomology of TD. They did not know what to say, how to respond, and how best to behave with someone who had delirium. Many caregivers had the impression that medication does not lessen delirium symptoms and that nonpharmacologic interventions are effective and beneficial only when they were important and meaningful to patients before delirium onset. CONCLUSIONS This study added new knowledge from direct and personal perspectives of caregivers providing end-of-life care to patients at home. Understanding developed about provision of care to someone with TD in home hospice. Improved comprehension of caregiver experiences can help professional hospice and palliative care staff better prepare caregivers for when patients have TD.
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Affiliation(s)
- Jacek T Soroka
- Chaplain Services, Mayo Clinic Health System, Mankato, MN, USA
| | - Krista J Fling
- Hospice Care, Mayo Clinic Health System, Mankato, MN, USA
| | | | | | - Sarah J Ward
- Social Services, Mayo Clinic Health System, Mankato, MN, USA
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4
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Ozga D, Krupa S, Witt P, Mędrzycka-Dąbrowska W. Nursing Interventions to Prevent Delirium in Critically Ill Patients in the Intensive Care Unit during the COVID19 Pandemic-Narrative Overview. Healthcare (Basel) 2020; 8:healthcare8040578. [PMID: 33371277 PMCID: PMC7766119 DOI: 10.3390/healthcare8040578] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 01/08/2023] Open
Abstract
It has become a standard measure in recent years to utilise evidence-based practice, which is associated with a greater need to implement and use advanced, reliable methods of summarising the achievements of various scientific disciplines, including such highly specialised approaches as personalised medicine. The aim of this paper was to discuss the current state of knowledge related to improvements in "nursing" involving management of delirium in intensive care units during the SARS-CoV-2 pandemic. This narrative review summarises the current knowledge concerning the challenges associated with assessment of delirium in patients with COVID-19 by ICU nurses, and the role and tasks in the personalised approach to patients with COVID-19.
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Affiliation(s)
- Dorota Ozga
- Institute of Health Sciences, Medical College of Rzeszow University, 35-310 Rzeszow, Poland; (D.O.); (S.K.)
| | - Sabina Krupa
- Institute of Health Sciences, Medical College of Rzeszow University, 35-310 Rzeszow, Poland; (D.O.); (S.K.)
| | - Paweł Witt
- Department of Pediatric Anesthesiology and Intensive Care, Medical University of Warsaw, 02-091 Warszawa, Poland;
| | - Wioletta Mędrzycka-Dąbrowska
- Department of Anaesthesiology Nursing & Intensive Care, Medical University in Gdansk, 80-211 Gdańsk, Poland
- Correspondence:
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5
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Nguyen MT, Feeney T, Kim C, Drake FT, Mitchell SE, Bednarczyk M, Sanchez SE. Patient-Level Factors Influencing Palliative Care Consultation at a Safety-Net Urban Hospital. Am J Hosp Palliat Care 2020; 38:1299-1307. [PMID: 33325245 DOI: 10.1177/1049909120981764] [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] [Indexed: 12/21/2022] Open
Abstract
The influence of patient-level factors on palliative and hospice care is unclear. We conducted a retrospective review of 2321 patients aged ≥18 that died within 6 months of admission to our institution between 2012 and 2017. Patients were included for analysis if their chart was complete, their length of stay was ≥48 hours, and if based on their diagnoses, they would have benefited from palliative care consultation (PCC). Bayesian regression with a weakly informative prior was used to find the odds ratio (OR) and 99% credible interval (CrI) of receiving PCC based on race/ethnicity, education, language, insurance status, and income. 730 patients fit our inclusion criteria and 30% (n = 211) received PCC. The OR of receiving PCC was 1.26 (99% CrI, 0.73-2.12) for Blacks, 0.81 (99% CrI, 0.31-1.86) for Hispanics, and 0.69 (99% CrI, 0.19-2.46) for other minorities. Less than high school education was associated with greater odds of PCC (OR 2.28, 99% CrI, 1.09-4.93) compared to no schooling. Compared to English speakers, non-English speakers had higher odds of receiving PCC when cared for by medical services (OR 3.01 [99% CrI, 1.44-5.32]) but lower odds of PCC when cared for by surgical services (0.22 [99% CrI, <0.01-3.42]). Insurance status and income were not associated with differences in PCC. At our institution, we found no evidence of racial/ethnic, insurance, or income status affecting PCC while primary language spoken and educational status did. Further investigation is warranted to examine the system and provider-level factors influencing PCC's low utilization by medical and surgical specialties.
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Affiliation(s)
| | - Timothy Feeney
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - F Thurston Drake
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Suzanne E Mitchell
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - Sabrina E Sanchez
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
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6
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Irvine FE, Clark MT, Efstathiou N, Herber OR, Howroyd F, Gratrix L, Sammut D, Trumm A, Hanssen TA, Taylor J, Bradbury-Jones C. The state of mixed methods research in nursing: A focused mapping review and synthesis. J Adv Nurs 2020; 76:2798-2809. [PMID: 32896959 DOI: 10.1111/jan.14479] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/31/2020] [Accepted: 07/14/2020] [Indexed: 12/29/2022]
Abstract
AIMS To consider the scope and quality of mixed methods research in nursing. DESIGN Focused mapping review and synthesis (FMRS). DATA SOURCES Five purposively selected journals: International Journal of Nursing Studies, Journal of Nursing Scholarship, Journal of Advanced Nursing, Worldviews on Evidence-Based Nursing, and Journal of Mixed Methods Research. REVIEW METHODS In the target journals, titles and abstracts from papers published between 2015-2018 were searched for the words or derivative words 'mixed methods'. Additional keyword searches were undertaken using each journal's search tool. We included studies that investigated nursing and reported to use a mixed methods approach. Articles that met the inclusion criteria were read in full and information was extracted onto a predetermined pro forma. Findings across journals were then synthesized to illustrate the current state of mixed methods research in nursing. RESULTS We located 34 articles that reported on mixed methods research, conducted across 18 countries. Articles differed significantly both within and across journals in terms of conformity to a mixed methods approach. We assessed the studies for the quality of their reporting as regard the use of mixed methods. Nineteen studies were rated as satisfactory or good, with 15 rated as poorly described. Primarily, a poor rating was due to the absence of stating an underpinning methodological approach to the study and/or limited detail of a crucial integration phase. CONCLUSIONS Our FMRS revealed a paucity of published mixed methods research in the journals selected. When they are published, there are limitations in the detail given to the underpinning methodological approach and theoretical explanation.
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Affiliation(s)
| | | | | | - Oliver R Herber
- Medical Faculty of the Heinrich Heine University Dusseldorf, Dusseldorf, Germany
| | - Fiona Howroyd
- Critical Care and Therapy Services, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Dana Sammut
- University of Birmingham, Birmingham, UK.,University Hospitals Birmingham, Birmingham, UK
| | | | - Tove A Hanssen
- UIT The Arctic University of Norway, Tromsø, Norway.,University Hospital of North Norway, Tromsø, Norway
| | - Julie Taylor
- University of Birmingham, Birmingham, UK.,Birmingham Women's and Children's Hospitals NHS Foundation Trust, Birmingham, UK
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7
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Abstract
Delirium is highly prevalent in people with advanced life limiting illness(es), and current evidence can inform how we provide best delirium care in this setting. Whilst strategies to prevent and reverse delirium are the cornerstones of optimal care, the care for delirious patients who are approaching the end of life and their families pose specific challenges particularly if delirium is refractory flagging a grave prognosis. These include addressing additional supportive care needs, clinical decision-making about the degree of investigation and intervention, minimising distress from the symptoms of delirium itself and considering other concurrent problems contributing to agitation. A fine balance is needed to address other symptoms such as pain whilst minimizing psychoactive medication load. There is need for regular and clear information and communication about prognosis and goals of care. Witnessing a delirium episode in a loved one in close proximity to death requires consideration of the needs of the family into bereavement care. Palliative care is person and family-centred care provided for a person with an active, progressive, advanced disease; who has little or no prospect of cure and who is expected to die, and for whom the primary treatment goal is to optimise quality of life. It is an approach which can be provided regardless of setting and diagnosis, and by both specialist palliative care teams and other health professionals.
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Affiliation(s)
- Meera R Agar
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation) Faculty of Health, University of Technology Sydney, Sydney, Australia
- South West Sydney Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
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8
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Young J, Hulme C, Smith A, Buckell J, Godfrey M, Holditch C, Grantham J, Tucker H, Enderby P, Gladman J, Teale E, Thiebaud JC. Measuring and optimising the efficiency of community hospital inpatient care for older people: the MoCHA mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background
Community hospitals are small hospitals providing local inpatient and outpatient services. National surveys report that inpatient rehabilitation for older people is a core function but there are large differences in key performance measures. We have investigated these variations in community hospital ward performance.
Objectives
(1) To measure the relative performance of community hospital wards (studies 1 and 2); (2) to identify characteristics of community hospital wards that optimise performance (studies 1 and 3); (3) to develop a web-based interactive toolkit that supports operational changes to optimise ward performance (study 4); (4) to investigate the impact of community hospital wards on secondary care use (study 5); and (5) to investigate associations between short-term community (intermediate care) services and secondary care utilisation (study 5).
Methods
Study 1 – we used national data to conduct econometric estimations using stochastic frontier analysis in which a cost function was modelled using significant predictors of community hospital ward costs. Study 2 – a national postal survey was developed to collect data from a larger sample of community hospitals. Study 3 – three ethnographic case studies were performed to provide insight into less tangible aspects of community hospital ward care. Study 4 – a web-based interactive toolkit was developed by integrating the econometrics (study 1) and case study (study 3) findings. Study 5 – regression analyses were conducted using data from the Atlas of Variation Map 61 (rate of emergency admissions to hospital for people aged ≥ 75 years with a length of stay of < 24 hours) and the National Audit of Intermediate Care.
Results
Community hospital ward efficiency is comparable with the NHS acute hospital sector (mean cost efficiency 0.83, range 0.72–0.92). The rank order of community hospital ward efficiencies was distinguished to facilitate learning across the sector. On average, if all community hospital wards were operating in line with the highest cost efficiency, savings of 17% (or £47M per year) could be achieved (price year 2013/14) for our sample of 101 wards. Significant economies of scale were found: a 1% rise in output was associated with an average 0.85% increase in costs. We were unable to obtain a larger community hospital sample because of the low response rate to our national survey. The case studies identified how rehabilitation was delivered through collaborative, interdisciplinary working; interprofessional communication; and meaningful patient and family engagement. We also developed insight into patients’ recovery trajectories and care transitions. The web-based interactive toolkit was established [http://mocha.nhsbenchmarking.nhs.uk/ (accessed 9 September 2019)]. The crisis response team type of intermediate care, but not community hospitals, had a statistically significant negative association with emergency admissions.
Limitations
The econometric analyses were based on cross-sectional data and were also limited by missing data. The low response rate to our national survey means that we cannot extrapolate reliably from our community hospital sample.
Conclusions
The results suggest that significant community hospital ward savings may be realised by improving modifiable performance factors that might be augmented further by economies of scale.
Future work
How less efficient hospitals might reduce costs and sustain quality requires further research.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- John Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
| | - Claire Hulme
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - Andrew Smith
- Institute for Transport Studies, University of Leeds, Leeds, UK
| | - John Buckell
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - Mary Godfrey
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
| | | | | | - Helen Tucker
- Community Hospitals Association, Crowborough, UK
| | - Pam Enderby
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Gladman
- University of Nottingham Medical School, University of Nottingham, Nottingham, UK
| | - Elizabeth Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
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9
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Godfrey M, Green J, Smith J, Cheater F, Inouye SK, Hurst K, Young J. Process of implementing and delivering the Prevention of Delirium system of care: a mixed method preliminary study. BMC Geriatr 2019; 20:1. [PMID: 31892317 PMCID: PMC6938603 DOI: 10.1186/s12877-019-1374-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/02/2019] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Delirium is a frequent complication of hospital admission among older people. Multicomponent interventions which can reduce incident delirium by ≈one-third are recommended by the National Institute of Health and Care Excellence. Currently, a standardised delirium prevention system of care suitable for adoption in the UK National Health Service does not exist. The Prevention of Delirium (POD) system of care is a theory informed, multicomponent intervention and systematic implementation process which includes a role for hospital volunteers. We report POD implementation and delivery processes in NHS hospital wards, as part of a feasibility study. METHODS A comparative case study design and participatory, multi-method evaluation was performed with sequential six month preparatory and six month delivery stages. Six wards in five hospitals in Northern England were recruited. Methods included: facilitated workshops; observation of POD preparatory activities; qualitative interviews with staff; collection of ward organisational and patient profiles; and structured observation of staff workload. RESULTS POD implementation and delivery was fully accomplished in four wards. On these wards, implementation strategies informed by Normalization Process Theory operated synergistically and cumulatively. An interactive staff training programme on delirium and practices that might prevent it among those at risk, facilitated purposeful POD engagement. Observation of practice juxtaposed to action on delirium preventive interventions created tension for change, legitimating new ways of organising work around it. Establishing systems, processes and documentation to make POD workable in the ward setting, enhanced staff ownership. 'Negotiated experimentation' to involve staff in creating, appraising and modifying systems and practices, helped integrate the POD care system in ward routines. Activating these change mechanisms required a particular form of leadership: pro-active 'steer', and senior ward 'facilitator' to extend 'reach' to the staff group. Organisational discontinuity (i.e. ward re-location and re-modelling) disrupted and extended POD implementation; staff shortages adversely affected staff capacity to invest in POD. Findings resulted in the development of 'site readiness' criteria without which implementation of this complex intervention was unlikely to occur. CONCLUSIONS POD implementation and delivery is feasible in NHS wards, but a necessary context for success is 'site readiness.'
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Affiliation(s)
- Mary Godfrey
- Academic Unit of Elderly Care and Rehabilitation, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, West Yorkshire, UK. .,Leeds Institute of Health Sciences, University of Leeds, Leeds, West Yorkshire, UK.
| | - John Green
- Academic Unit of Elderly Care and Rehabilitation, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, West Yorkshire, UK
| | - Jane Smith
- Academic Unit of Elderly Care and Rehabilitation, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, West Yorkshire, UK
| | - Francine Cheater
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Sharon K Inouye
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Keith Hurst
- , Independent Researcher, Kings Lynn, Norfolk Island
| | - John Young
- Academic Unit of Elderly Care and Rehabilitation, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, West Yorkshire, UK
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10
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Hosie A, Siddiqi N, Featherstone I, Johnson M, Lawlor PG, Bush SH, Amgarth-Duff I, Edwards L, Cheah SL, Phillips J, Agar M. Inclusion, characteristics and outcomes of people requiring palliative care in studies of non-pharmacological interventions for delirium: A systematic review. Palliat Med 2019; 33:878-899. [PMID: 31250725 DOI: 10.1177/0269216319853487] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Delirium is common, distressing, serious and under-researched in specialist palliative care settings. OBJECTIVES To examine whether people requiring palliative care were included in non-pharmacological delirium intervention studies in inpatient settings, how they were characterised and what their outcomes were. DESIGN Systematic review (PROSPERO 2017 CRD42017062178). DATA SOURCES Systematic search in March 2017 for non-pharmacological delirium intervention studies in adult inpatients. Database search terms were 'delirium', 'hospitalisation', 'inpatient', 'palliative care', 'hospice', 'critical care' and 'geriatrics'. Scottish Intercollegiate Guidelines Network methodological checklists guided risk of bias assessment. RESULTS The 29 included studies were conducted between 1994 and 2015 in diverse settings in 15 countries (9136 participants, mean age = 76.5 years (SD = 8.1), 56% women). Most studies tested multicomponent interventions (n = 26) to prevent delirium (n = 19). Three-quarters of the 29 included studies (n = 22) excluded various groups of people requiring palliative care; however, inclusion criteria, participant diagnoses, illness severity and mortality indicated their presence in almost all studies (n = 26). Of these, 21 studies did not characterise participants requiring palliative care or report their specific outcomes (72%), four reported outcomes for older people with frailty, dementia, cancer and comorbidities, and one was explicitly focused on people receiving palliative care. Study heterogeneity and limitations precluded definitive determination of intervention effectiveness and only allowed interpretations of feasibility for people requiring palliative care. Acceptability outcomes (intervention adverse events and patients' subjective experience) were rarely reported overall. CONCLUSION Non-pharmacological delirium interventions have frequently excluded and under-characterised people requiring palliative care and infrequently reported their outcomes.
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Affiliation(s)
- Annmarie Hosie
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | | | | | - Peter G Lawlor
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Layla Edwards
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Jane Phillips
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meera Agar
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
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11
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Nguyen MT, Feeney T, Kim C, Drake FT, Mitchell SE, Bednarczyk M, Sanchez SE. Differential Utilization of Palliative Care Consultation Between Medical and Surgical Services. Am J Hosp Palliat Care 2019; 37:250-257. [PMID: 31387366 DOI: 10.1177/1049909119867904] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
There is a paucity of data regarding the utilization of palliative care consultation (PCC) in surgical specialties. We conducted a retrospective review of 2321 adult patients (age ≥18) who died within 6 months of admission to Boston Medical Center from 2012 to 2017. Patients were included for analysis if their length of stay was more than 48 hours and if, based on their diagnoses as determined by literature review and expert consensus, they would have benefited from PCC. Bayesian regression was used to estimate the odds ratio (OR) and 99% credible intervals (CrI) of receiving PCC adjusted for age, sex, race, insurance status, median income, and comorbidity status. Among the 739 patients who fit the inclusion criteria, only 30% (n = 222) received PCC even though 664 (90%) and 75 (10%) of these patients were identified as warranting PCC on medical and surgical services, respectively. Of the 222 patients who received PCC, 214 (96%) were cared for by medical services and 8 (4%) were cared for by surgical services. Patients cared for primarily by surgical were significantly less likely to receive PCC than primary patients of medical service providers (OR, 0.19, 99% CrI, 0.056-0.48). At our institution, many surgical patients appropriate for PCC are unable to benefit from this service due to low consultation numbers. Further investigation is warranted to examine if this phenomenon is observed at other institutions, elucidate the reasons for this disparity, and develop interventions to increase the appropriate use of PCC throughout all medical specialties.
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Affiliation(s)
| | - Timothy Feeney
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Chanmin Kim
- Boston University School of Public Health, Boston, MA, USA
| | - F Thurston Drake
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Suzanne E Mitchell
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - Sabrina E Sanchez
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
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Hosie A, Phillips J, Lam L, Kochovska S, Noble B, Brassil M, Kurrle SE, Cumming A, Caplan GA, Chye R, Le B, Ely EW, Lawlor PG, Bush SH, Davis JM, Lovell M, Brown L, Fazekas B, Cheah SL, Edwards L, Agar M. Multicomponent non-pharmacological intervention to prevent delirium for hospitalised people with advanced cancer: study protocol for a phase II cluster randomised controlled trial. BMJ Open 2019; 9:e026177. [PMID: 30696686 PMCID: PMC6352777 DOI: 10.1136/bmjopen-2018-026177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Delirium is a significant medical complication for hospitalised patients. Up to one-third of delirium episodes are preventable in older inpatients through non-pharmacological strategies that support essential human needs, such as physical and cognitive activity, sleep, hydration, vision and hearing. We hypothesised that a multicomponent intervention similarly may decrease delirium incidence, and/or its duration and severity, in inpatients with advanced cancer. Prior to a phase III trial, we aimed to determine if a multicomponent non-pharmacological delirium prevention intervention is feasible and acceptable for this specific inpatient group. METHODS AND ANALYSIS The study is a phase II cluster randomised wait-listed controlled trial involving inpatients with advanced cancer at four Australian palliative care inpatient units. Intervention sites will introduce delirium screening, diagnostic assessment and a multicomponent delirium prevention intervention with six domains of care: preserving natural sleep; maintaining optimal vision and hearing; optimising hydration; promoting communication, orientation and cognition; optimising mobility; and promoting family partnership. Interdisciplinary teams will tailor intervention delivery to each site and to patient need. Control sites will first introduce only delirium screening and diagnosis, later implementing the intervention, modified according to initial results. The primary outcome is adherence to the intervention during the first seven days of admission, measured for 40 consecutively admitted eligible patients. Secondary outcomes relate to fidelity and feasibility, acceptability and sustainability of the study intervention, processes and measures in this patient population, using quantitative and qualitative measures. Delirium incidence and severity will be measured to inform power calculations for a future phase III trial. ETHICS AND DISSEMINATION Ethical approval was obtained for all four sites. Trial results, qualitative substudy findings and implementation of the intervention will be submitted for publication in peer-reviewed journals, and reported at conferences, to study sites and key peak bodies. TRIAL REGISTRATION NUMBER ACTRN12617001070325; Pre-results.
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Affiliation(s)
- Annmarie Hosie
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jane Phillips
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Lawrence Lam
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Slavica Kochovska
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Beverly Noble
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Meg Brassil
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Susan E Kurrle
- Hornsby Ku-ring-gai Health Service, Northern Clinical School, University of Sydney, Hornsby, New South Wales, Australia
| | - Anne Cumming
- Australian Commission on Safety and Quality in Healthcare, Sydney, New South Wales, Australia
| | - Gideon A Caplan
- Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Randwick, New South Wales, Australia
| | - Richard Chye
- Sacred Heart Health Service, St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
| | - Brian Le
- Palliative and Supportive Services, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt University, and the Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville TN USA, Nashville, Tennessee, USA
| | - Peter G Lawlor
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jan Maree Davis
- Palliative Care, Calvary Health Care Kogarah, Sydney, New South Wales, Australia
| | - Melanie Lovell
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
- Hornsby Ku-ring-gai Health Service, Northern Clinical School, University of Sydney, Hornsby, New South Wales, Australia
- HammondCare, Greenwich Hospital, Greenwich, New South Wales, Australia
| | - Linda Brown
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Belinda Fazekas
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Seong Leang Cheah
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Layla Edwards
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Meera Agar
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
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Phillips J, Hosie A. Imprecise communication and perceptions of palliative care. Int J Palliat Nurs 2018; 24:55. [PMID: 29469648 DOI: 10.12968/ijpn.2018.24.2.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jane Phillips
- Professor of Palliative Nursing and Director, IMPACCT, Faculty of Health, University of Technology, Sydney, Australia
| | - Annmarie Hosie
- Post-doctoral Research Fellow, IMPACCT, Faculty of Health, University of Technology, Sydney, Australia
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