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Levine O, Bainbridge D, Pond GR, Slaven M, Dhesy-Thind S, Sussman J, Meyer RM. Patient and Provider Attitudes and Preferences Regarding Early Palliative Care Delivery for Patients with Advanced Gastrointestinal Cancers: A Prospective Survey. Curr Oncol 2024; 31:3329-3341. [PMID: 38920736 PMCID: PMC11203221 DOI: 10.3390/curroncol31060253] [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: 05/02/2024] [Revised: 06/04/2024] [Accepted: 06/10/2024] [Indexed: 06/27/2024] Open
Abstract
Early integrated palliative care (EIPC) for patients with advanced cancers requires the involvement of family doctors (FDs) and oncologists. We compared attitudes between patients and their providers regarding the delivery of EIPC. Patients with newly diagnosed incurable gastrointestinal (GI) cancer at a tertiary cancer centre in Ontario, Canada, were surveyed using a study-specific instrument regarding the importance of and preferences for accessing support across eight domains of palliative care. Physicians within the circle of care completed a parallel survey for each patient. The concordance between patient and physician responses was analyzed. A total of 66 patients were surveyed (median age 69, 35% female). All had an oncologist, 12% had a specialist palliative care provider (SPC), and 97% had an FD, but only 41% listed the FD as part of the care team. In total, 95 providers responded (oncologist = 68, FD = 21, SPC = 6; response rate 92%; 1-3 physician responses per patient). Disease management and physical concerns were most important to patients. Patients preferred to access care in these domains from oncologists or SPCs. For all other domains, most patients attributed primary responsibility to self or family rather than any healthcare provider. Thus, concordance was poor between patient and physician responses. Across most domains of palliative care, we found low agreement between cancer patients and their physicians regarding responsibilities for care, with FDs appearing to have limited involvement at this stage.
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Affiliation(s)
- Oren Levine
- Department of Oncology, McMaster University, Hamilton, ON L8S 4L8, Canada; (D.B.)
| | - Daryl Bainbridge
- Department of Oncology, McMaster University, Hamilton, ON L8S 4L8, Canada; (D.B.)
| | - Gregory R. Pond
- Department of Oncology, McMaster University, Hamilton, ON L8S 4L8, Canada; (D.B.)
| | - Marissa Slaven
- Department of Family Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
| | | | - Jonathan Sussman
- Department of Oncology, McMaster University, Hamilton, ON L8S 4L8, Canada; (D.B.)
| | - Ralph M. Meyer
- Department of Oncology, McMaster University, Hamilton, ON L8S 4L8, Canada; (D.B.)
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Iupati S, Stanley J, Egan R, MacLeod R, Davies C, Spence H, Iupati D, Middlemiss T, Gwynne-Robson I. Systematic Review of Models of Effective Community Specialist Palliative Care Services for Evidence of Improved Patient-Related Outcomes, Equity, Integration, and Health Service Utilization. J Palliat Med 2023; 26:1562-1577. [PMID: 37366688 DOI: 10.1089/jpm.2022.0461] [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: 06/28/2023] Open
Abstract
Background: The benefits of palliative care programs are well documented. However, the effectiveness of specialist palliative care services is not well established. The previous lack of consensus on criteria for defining and characterizing models of care has restrained direct comparison between these models and limited the evidence base to inform policy makers. A rapid review for studies published up to 2012 was unable to find an effective model. Aim: To identify effective models of community specialist palliative care services. Design: A mixed-method synthesis design reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Prospero: CRD42020151840. Data sources: Medline, PubMed, EMBASE, CINAHL and the Cochrane Database of Systematic Reviews were searched in September 2019 for primary research and review articles from 2012 to 2019. Supplementary search was conducted on Google in 2020 for policy documents to identify additional relevant studies. Results: The search yielded 2255 articles; 36 articles satisfied the eligibility criteria and 6 additional articles were identified from other sources. Eight systematic reviews and 34 primary studies were identified: observational studies (n = 24), randomized controlled trials (n = 5), and qualitative studies (n = 5). Community specialist palliative care was found to improve symptom burden/quality of life and to reduce secondary service utilization across cancer and noncancer diagnoses. Much of this evidence relates to face-to-face care in home-based settings with both round-the-clock and episodic care. There were few studies addressing pediatric populations or minority groups. Findings from qualitative studies revealed that care coordination, provision of practical help, after-hours support, and medical crisis management were some of the factors contributing to patients' and caregivers' positive experience. Conclusion: Strong evidence exists for community specialist palliative care to improve quality of life and reducing secondary service utilization. Future research should focus on equity outcomes and the interface between generalist and specialist care.
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Affiliation(s)
- Salina Iupati
- Department of Preventive and Social Medicine, University of Otago Dunedin School of Medicine, Dunedin, New Zealand
- Te Omanga Hospice, Lower Hutt, New Zealand
| | - James Stanley
- Biostatistics Group, University of Otago, Wellington, New Zealand
| | - Richard Egan
- Department of Preventive and Social Medicine, University of Otago Dunedin School of Medicine, Dunedin, New Zealand
| | - Roderick MacLeod
- Department of General Practice and Primary Care, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Cheryl Davies
- Tu Kotahi Māori Asthma and Research Trust, Lower Hutt, New Zealand
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Atreya S, Salins N. End-of-Life Care Education as Blended Learning Approach for General Practitioners: a Scoping Review. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2023; 38:1440-1458. [PMID: 37648949 PMCID: PMC10509089 DOI: 10.1007/s13187-023-02358-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
General practitioners (GPs) are critical in providing primary palliative care in the community. Apprehensions about managing a dying person at home, difficulties in goals of care discussion, limited resources and lack of palliative care education often hinder end-of-life care provision in the community. This review focused on the end-of-life care training programs accessed by GPs and sought to understand if the training programs' content and mode of delivery aligned with their preferred needs. MEDLINE, EMBASE, CINAHL, and PsycINFO were searched to identify articles published in English between 01 January 1990 and 30 September 2022. Additionally, searches were conducted using SCOPUS, the Web of Science, and the Cochrane database using free texts. The reviewers screened the titles, abstracts, and full text to identify eligible studies and extracted textual data to analyse and generate themes. Out of 5532 citations initially accessed, 17 studies were included in the review. Six themes were generated: knowledge translation, skill development, a change in attitude, self-efficacy, satisfaction, and patient outcomes. The GPs' end-of-life care knowledge, skills, attitude, self-efficacy, and patient outcomes were better when their training had a combination of small-group interactive workshops, trigger case-based reflective learning, mentor-facilitated experiential learning, web-based modules, and peer learning. The synthesis of review findings supports blended learning as a training approach for general the practitioners' end-of-life care education as it facilitates learning and patient outcomes.
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Affiliation(s)
- Shrikant Atreya
- Department of Palliative Care and Psycho-Oncology, Tata Medical Center, Kolkata, West Bengal, 700160, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
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4
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Hughes MC, Vernon E, Hainstock A. The effectiveness of community-based palliative care programme components: a systematic review. Age Ageing 2023; 52:afad175. [PMID: 37740895 PMCID: PMC10517647 DOI: 10.1093/ageing/afad175] [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: 12/01/2022] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND There is evidence that community-based palliative care programmes can improve patient outcomes and caregiver experiences cost-effectively. However, little is known about which specific components within these programmes contribute to improving the outcomes. AIM To systematically review research that evaluates the effectiveness of community-based palliative care components. DESIGN A systematic mixed studies review synthesising quantitative, qualitative and mixed-methods study findings using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PROSPERO: ID # CRD42022302305. DATA SOURCES Four databases were searched in August 2021 (CINAHL, Web of Science, ProQuest Federated and PubMed including MEDLINE) and a close review of included article references. Inclusion criteria required articles to evaluate a single, specific component of a community-based palliative care programme either within an individual programme or across several programmes. RESULTS Overall, a total of 1,674 articles were identified, with 57 meeting the inclusion criteria. Of the included studies, 21 were qualitative, 25 were quantitative and 11 had mixed methods. Outcome measures consistently examined included patient/caregiver satisfaction, hospital utilisation and home deaths. The components of standardised sessions (interdisciplinary meetings about patients), volunteer engagement and early intervention contributed to the success of community-based palliative care programmes. CONCLUSIONS Certain components of community-based palliative care programmes are effective. Such components should be implemented and tested more in low- and middle-income countries and key and vulnerable populations such as lower-income and marginalised racial or ethnic groups. In addition, more research is needed on the cost-effectiveness of individual programme components.
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Affiliation(s)
- M Courtney Hughes
- Department of Public Health, Northern Illinois University, DeKalb, IL 60115, USA
| | - Erin Vernon
- Department of Economics, Seattle University, Seattle, WA 98122, USA
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5
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Philip J, Collins A, Warwyk O, Sundararajan V, Le B. Is the use of palliative care services increasing? A comparison of current versus historical palliative care access using health service datasets for patients with cancer. Palliat Med 2022; 36:1426-1431. [PMID: 36002977 DOI: 10.1177/02692163221118205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mature evidence exists supporting the integration of palliative care in cancer care, but translation of evidence into practice is less well understood. AIM We sought to understand current access to palliative care and its timing for people with cancer and to compare practices over time. DESIGN We conducted a retrospective population cohort study using routinely collected administrative health data sets in Victoria, Australia. SETTING/PARTICIPANTS All adult cancer decedents in 2018 were identified and clinical, demographic, palliative care access and quality of end of life care indices collected.Comparisons between a historic cohort of lung, breast and prostate cancer patients who died between the years 2005 and 2009 and those with these diagnoses in the current cohort. RESULTS In 2018 there were 10,245 Victorian decedents with a cancer-coded cause of death, of these 3689 had lung, prostate or breast cancer. In 2018, access to palliative care increased (66% vs 54%) and greater numbers accessed palliative care more than 3 months before death (18% vs 10%) than in 2005-2009. Indices of end of life quality improved across most domains. However the median time between first palliative care and death was shorter in 2018 (22 vs 25 days) and more people first accessed palliative care in the hospitalisation during which they died (43% vs 33%). CONCLUSION Despite established benefits of early palliative care, the important task of translation of this evidence into practice remains.
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Affiliation(s)
- Jennifer Philip
- Department of Medicine, University of Melbourne, Parkville, Australia.,St Vincent's Hospital, Fitzroy, Australia.,Peter MacCallum Cancer Centre, Parkville, Australia.,Royal Melbourne Hospital, Parkville, Australia
| | - Anna Collins
- Department of Medicine, University of Melbourne, Parkville, Australia
| | - Olivia Warwyk
- Department of Medicine, University of Melbourne, Parkville, Australia
| | - Vijaya Sundararajan
- Department of Medicine, University of Melbourne, Parkville, Australia.,Department of Public Health, LaTrobe University, Bundoora, Australia
| | - Brian Le
- Department of Medicine, University of Melbourne, Parkville, Australia.,Peter MacCallum Cancer Centre, Parkville, Australia.,Royal Melbourne Hospital, Parkville, Australia
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Ryan RE, Connolly M, Bradford NK, Henderson S, Herbert A, Schonfeld L, Young J, Bothroyd JI, Henderson A. Interventions for interpersonal communication about end of life care between health practitioners and affected people. Cochrane Database Syst Rev 2022; 7:CD013116. [PMID: 35802350 PMCID: PMC9266997 DOI: 10.1002/14651858.cd013116.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes. OBJECTIVES To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing. SELECTION CRITERIA This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life, we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes. DATA COLLECTION AND ANALYSIS Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies. MAIN RESULTS Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials. Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication. Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations. Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life. Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear. AUTHORS' CONCLUSIONS Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.
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Affiliation(s)
- Rebecca E Ryan
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Michael Connolly
- School of Nursing, Midwifery and Health Systems, University College Dublin and Our Lady's Hospice and Care Services, Dublin, Ireland
| | - Natalie K Bradford
- Centre for Children's Health Research, Cancer and Palliative Care Outcomes at Centre for Children's Health Research, Queensland University of Technology (QUT), South Brisbane, Australia
| | - Simon Henderson
- Department of Aviation, The University of New South Wales, Sydney, Australia
| | - Anthony Herbert
- Paediatric Palliative Care Service, Children's Health Queensland, Hospital and Health Service, South Brisbane, Australia
- Centre for Children's Health Research, Queensland University of Technology, South Brisbane, Australia
| | - Lina Schonfeld
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Jeanine Young
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, Australia
| | | | - Amanda Henderson
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, Australia
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7
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Boaventura JR, Pessalacia JDR, Ribeiro AA, de Souza FB, da Silva Neto PK, Marinho MR. Palliative care in the pre-hospital service in Brazil: experiences of health professionals. BMC Palliat Care 2022; 21:4. [PMID: 34980088 PMCID: PMC8725435 DOI: 10.1186/s12904-021-00890-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/06/2021] [Indexed: 11/30/2022] Open
Abstract
Background An integrated care network between emergency, specialized and primary care services can prevent repeated hospitalizations and the institutionalized death of terminally ill patients in palliative care (PC). To identify the perception of health professionals regarding the concept of PC and their care experiences with this type of patient in a pre-hospital care (PHC) service in Brazil. Methods Study with a qualitative approach, of interpretative nature, based on the perspective of Ricoeur’s Dialectical Hermeneutics. Results Three central themes emerged out of the professionals’ speeches: (1) unpreparedness of the team, (2) decision making, and (3) dysthanasia. Conclusions It is necessary to invest in professional training associated with PC in the home context and its principles, such as: affirming life and considering death as a normal process not rushing or postponing death; integrating the psychological and spiritual aspects of patient and family care, including grief counseling and improved quality of life, adopting a specific policy for PC that involves all levels of care, including PHC, and adopt a unified information system, as well as more effective procedures that favor the respect for the patients’ will, without generating dissatisfaction to the team and the family.
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Affiliation(s)
- Jacqueline Resende Boaventura
- Federal University of Mato Grosso do Sul (UFMS), Av. Ranulpho Marques Leal, n° 3484, Três Lagoas, MS, Caixa-postal: 210, Brazil
| | - Juliana Dias Reis Pessalacia
- Federal University of Mato Grosso do Sul (UFMS), Av. Ranulpho Marques Leal, n° 3484, Três Lagoas, MS, Caixa-postal: 210, Brazil.
| | - Aridiane Alves Ribeiro
- Federal University of Goiás (UFG)Federal University of Jataí (UFJ), BR 364, km 195, n° 3800, Jataí, GO, Brazil
| | - Fabiana Bolela de Souza
- University of São Paulo, Ribeirão Preto School of Nursing (USP), Avenida dos Bandeirantes, 3900 - Campus Universitário - Bairro Monte Alegre, Ribeirão Preto, SP, Brazil
| | - Priscila Kelly da Silva Neto
- Federal University of Mato Grosso do Sul (UFMS), Av. Ranulpho Marques Leal, n° 3484, Três Lagoas, MS, Caixa-postal: 210, Brazil
| | - Maristela Rodrigues Marinho
- Federal University of Mato Grosso do Sul (UFMS), Av. Ranulpho Marques Leal, n° 3484, Três Lagoas, MS, Caixa-postal: 210, Brazil
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8
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Wyatt K, Bastaki H, Davies N. Delivering end-of-life care for patients with cancer at home: Interviews exploring the views and experiences of general practitioners. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e126-e137. [PMID: 33970526 DOI: 10.1111/hsc.13419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/23/2021] [Accepted: 04/08/2021] [Indexed: 06/12/2023]
Abstract
Many patients with terminal cancer wish to die at home and general practitioners in the United Kingdom have a critical role in providing this care. However, it has been suggested general practitioners lack confidence in end-of-life care. It is important to explore with general practitioners their experience and perspectives including feelings of confidence delivering end-of-life care to people with cancer. The aim of this study was to explore general practitioners experiences of providing end-of-life care for people with cancer in the home setting and their perceptions of confidence in this role as well as understanding implications this has on policy design. A qualitative study design was employed using semi-structured interviews and analysed using thematic analysis. Nineteen general practitioners from London were purposively sampled from eight general practices and a primary care university department in 2018-2019, supplemented with snowballing methods. Five main themes were constructed: (a) the subjective nature of defining palliative and end-of-life care; (b) importance of communication and managing expectations; (c) complexity in prescribing; (d) challenging nature of delivering end-of-life care; (e) the unclear role of primary care in palliative care. General practitioners viewed end-of-life care as challenging; specific difficulties surrounded communication and prescribing. These challenges coupled with a poorly defined role created a spread in perceived confidence. Experience and exposure were seen as enabling confidence. Specialist palliative care service expansion had important implications on deskilling of essential competencies and reducing confidence levels in general practitioners. This feeds into a complex cycle of causation, leading to further delegation of care.
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Affiliation(s)
- Kelly Wyatt
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Hamad Bastaki
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Nathan Davies
- Research Department of Primary Care and Population Health, University College London, London, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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9
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Mitchell G, Melaku M, Moss A, Chaille G, Makoni B, Lewis L, Mutch A. Evaluation of a commissioned end-of-life care service in Australian aged care facilities. PROGRESS IN PALLIATIVE CARE 2021. [DOI: 10.1080/09699260.2021.1905146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Geoffrey Mitchell
- Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Megdelawit Melaku
- Faculty of Medicine, The University of Queensland, Herston, Australia
| | | | | | | | | | - Allyson Mutch
- Faculty of Medicine, The University of Queensland, Herston, Australia
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10
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Barnes-Harris M, Allingham S, Morgan D, Ferreira D, Johnson MJ, Eagar K, Currow D. Comparing functional decline and distress from symptoms in people with thoracic life-limiting illnesses: lung cancers and non-malignant end-stage respiratory diseases. Thorax 2021; 76:989-995. [PMID: 33593929 DOI: 10.1136/thoraxjnl-2020-216039] [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: 08/23/2020] [Revised: 12/23/2020] [Accepted: 02/01/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Malignant and non-malignant respiratory diseases account for >4.6 million deaths annually worldwide. Despite similar symptom burdens, serious inequities in access to palliative care persists for people with non-malignant respiratory diseases. AIM To compare functional decline and symptom distress in advanced malignant and non-malignant lung diseases using consecutive, routinely collected, point-of-care national data. SETTING/PARTICIPANTS The Australian national Palliative Care Outcomes Collaboration collects functional status (Australia-modified Karnofsky Performance Status (AKPS)) and symptom distress (patient-reported 0-10 numerical rating scale) in inpatient and community settings. Five years of data used Joinpoint and weighted scatterplot smoothing. RESULTS In lung cancers (89 904 observations; 18 586 patients) and non-malignant end-stage respiratory diseases (14 827 observations; 4279 patients), age at death was significantly lower in people with lung cancer (73 years; IQR 65-81) than non-malignant end-stage respiratory diseases (81 years; IQR 73-87 years; p<0.001). Four months before death, median AKPS was 40 in lung cancers and 30 in non-malignant end-stage respiratory diseases (p<0.001). Functional decline was similar in the two groups and accelerated in the last month of life. People with non-malignant diseases accessed palliative care later.Pain-related distress was greater with cancer and breathing-related distress with non-malignant disease. Breathing-related distress increased towards death in malignant, but decreased in non-malignant disease. Distress from fatigue and poor sleep were similar for both. CONCLUSIONS In this large dataset unlike previous datasets, the pattern of functional decline was similar as was overall symptom burden. Timely access to palliative care should be based on needs not diagnoses.
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Affiliation(s)
| | - Samuel Allingham
- Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Deidre Morgan
- Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, South Australia, Australia
| | - Diana Ferreira
- Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, South Australia, Australia
| | - Miriam J Johnson
- Hull York Medical School, University of Hull, Hull, England.,Wolfson Palliative Care Research Centre, University of Hull, Hull, England
| | - Kathy Eagar
- Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - David Currow
- Wolfson Palliative Care Research Centre, University of Hull, Hull, England .,IMPACCT, University of Technology Sydney, Sydney, New South Wales, Australia
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11
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Mitchell G, Murray SA. Supportive and palliative care in the age of deferred death: primary care's central role. BMJ Support Palliat Care 2020; 11:398-400. [PMID: 32973109 DOI: 10.1136/bmjspcare-2020-002616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Geoffrey Mitchell
- Mayne Academy of General Practice, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Scott A Murray
- Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics, Primary Palliative Care Research Group, The University of Edinburgh, Edinburgh, UK
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12
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Mitchell G, Aubin M, Senior H, Johnson C, Fallon-Ferguson J, Williams B, Monterosso L, Rhee JJ, McVey P, Grant M, Nwachukwu H, Yates P. General practice nurses and physicians and end of life: a systematic review of models of care. BMJ Support Palliat Care 2020:bmjspcare-2019-002114. [PMID: 32718955 DOI: 10.1136/bmjspcare-2019-002114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 04/28/2020] [Accepted: 06/02/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND General practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide palliative care (PC) or end-of-life care (EoLC) as the population ages. In order to maximise the impact of GPs and GPNs, the impact of different models of care that have been developed to support their practice of EoLC needs to be understood. OBJECTIVE To examine published models of EoLC that incorporate or support GP and GPN practice, and their impact on patients, families and the health system. METHOD Systematic literature review. Data included papers (2000 to 2017) sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases. RESULTS From 6209 journal articles, 13 papers reported models of care supporting the GP and GPN's role in EoLC or PC practice. Services and guidelines for clinical issues have mixed impact on improving symptoms, but improved adherence to clinical guidelines. National Frameworks facilitated patients being able to die in their preferred place. A single specialist PC-GP case conference reduced hospitalisations, better maintained functional capacity and improved quality of life parameters in both patients with cancer and without cancer. No studies examined models of care aimed at supporting GPNs. CONCLUSIONS Primary care practitioners have a natural role to play in EoLC, and most patient and health system outcomes are substantially improved with their involvement. Successful integrative models need to be tested, particularly in non-malignant diseases. Such models need to be explored further. More work is required on the role of GPNs and how to support them in this role.
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Affiliation(s)
- Geoffrey Mitchell
- Primary Care Clinical Unit, University of Queensland, Herston, Queensland, Australia
| | - Michèle Aubin
- Département de médecine familiale et de médecine d'urgence, Faculté de médecine, Université Laval, Quebec City, Quebec, Canada
| | - Hugh Senior
- Primary Care Clinical Unit, University of Queensland, Herston, Queensland, Australia
- College of Health, Massey University, Auckland, New Zealand
| | - Claire Johnson
- Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
- Medical School, The University of Western Australia, Crawley, Western Australia, Australia
| | - Julia Fallon-Ferguson
- Primary Care Collaborative Cancer Clinical Trials Group, The University of Melbourne, Melbourne, Victoria, Australia
- General Practice, University of Western Australia, Perth, Western Australia, Australia
| | - Briony Williams
- Primary Care Collaborative Cancer Clinical Trials Group, The University of Melbourne, Melbourne, Victoria, Australia
- General Practice, University of Western Australia, Perth, Western Australia, Australia
| | - Leanne Monterosso
- School of Nursing, Notre Dame University, Perth, Western Australia, Australia
- School of Nursing, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Joel J Rhee
- General Practice Unit, University of Wollongong, Wollongong, New South Wales, Australia
| | - Peta McVey
- Susan Wakil School of Nursing, University of Sydney, Sydney, New South Wales, Australia
| | - Matthew Grant
- School of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Harriet Nwachukwu
- Primary Care Clinical Unit, University of Queensland, Herston, Queensland, Australia
| | - Patsy Yates
- Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
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Rhee JJ, Grant M, Senior H, Monterosso L, McVey P, Johnson C, Aubin M, Nwachukwu H, Bailey C, Fallon-Ferguson J, Yates P, Williams B, Mitchell G. Facilitators and barriers to general practitioner and general practice nurse participation in end-of-life care: systematic review. BMJ Support Palliat Care 2020:bmjspcare-2019-002109. [PMID: 32561549 DOI: 10.1136/bmjspcare-2019-002109] [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: 11/09/2019] [Revised: 04/17/2020] [Accepted: 05/04/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND General practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide palliative care (PC) or end-of-life care (EoLC) as the population ages. To enhance primary EoLC, the facilitators and barriers to their provision need to be understood. OBJECTIVE To provide a comprehensive description of the facilitators and barriers to GP and GPN provision of PC or EoLC. METHOD Systematic literature review. Data included papers (2000 to 2017) sought from Medline, PsycInfo, Embase, Joanna Briggs Institute and Cochrane databases. RESULTS From 6209 journal articles, 62 reviewed papers reported the GP's and GPN's role in EoLC or PC practice. Six themes emerged: patient factors; personal GP factors; general practice factors; relational factors; co-ordination of care; availability of services. Four specific settings were identified: aged care facilities, out-of-hours care and resource-constrained settings (rural, and low-income and middle-income countries). Most GPs provide EoLC to some extent, with greater professional experience leading to increased comfort in performing this form of care. The organisation of primary care at practice, local and national level impose numerous structural barriers that impede more significant involvement. There are potential gaps in service provision where GPNs may provide significant input, but there is a paucity of studies describing GPN routine involvement in EoLC. CONCLUSIONS While primary care practitioners have a natural role to play in EoLC, significant barriers exist to improved GP and GPN involvement in PC. More work is required on the role of GPNs.
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Affiliation(s)
- Joel J Rhee
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Matthew Grant
- School of Medicine, Monash University, Clayton, Victoria, Australia
| | - Hugh Senior
- College of Health Sciences, Massey University-Albany Campus, Auckland, New Zealand
| | - Leanne Monterosso
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
- School of Nursing, University of Notre Dame, Fremantly, Western Australia, Australia
| | - Peta McVey
- Susan Wakil School of Nursing, University of Sydney, Sydney, New South Wales, Australia
| | - Claire Johnson
- Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
- Cancer and Palliative Care Research and Evaluation Unit, School of Surgery, The University of Western Australia, Perth, Western Australia, Australia
| | - Michèle Aubin
- Département de médecine familiale et de médecine d'urgence, Laval University Faculty of Medicine, Quebec City, Quebec, Canada
| | - Harriet Nwachukwu
- Primary Care Clinical Unit, The University of Queensland Faculty of Medicine, Herston, Queensland, Australia
| | - Claire Bailey
- School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Julia Fallon-Ferguson
- General Practice, The University of Western Australia, Perth, Western Australia, Australia
- Primary Care Cancer Clinical Trials Collaborative, University of Melbourne, Melbourne, Victoria, Australia
| | - Patsy Yates
- Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Briony Williams
- General Practice, The University of Western Australia, Perth, Western Australia, Australia
- Primary Care Cancer Clinical Trials Collaborative, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, The University of Queensland Faculty of Medicine, Herston, Queensland, Australia
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14
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Currow DC, Agar MR, Phillips JL. Role of Hospice Care at the End of Life for People With Cancer. J Clin Oncol 2020; 38:937-943. [DOI: 10.1200/jco.18.02235] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Patient-defined factors that are important at the end of life include being physically independent for as long as possible, good symptom control, and spending quality time with friends and family. Hospice care adds to the quality of care and these patient-centered priorities for people with cancer and their families in the last weeks and days of life. Evidence from large observational studies demonstrate that hospice care can improve outcomes directly and support better and more appropriate health care use for people in the last stages of cancer. Team-based community hospice care has measurable benefits for patients, their family caregivers, and health services. In addition to improved symptom control for patients and a greater likelihood of time spent at home, caregiver outcomes are better when hospice care is accessed: informational needs are better met, and caregivers have an improved ability to move on with life after the patient’s death compared with people who did not have access to these services. Hospice care continues to evolve as its reach expands and the needs of patients continue to broaden. This is reflected in the transition from hospice being based on excellence in nursing to teams with a broad range of health professionals to meet the complex and changing needs of patients and their families. Additional integration of cancer services with hospice care will help to provide more seamless care for patients and supporting family caregivers during their caregiving and after the death of the patient.
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Affiliation(s)
- David C. Currow
- University of Technology Sydney, Ultimo, NSW, Australia
- University of Hull, Hull, United Kingdom
| | - Meera R. Agar
- University of Technology Sydney, Ultimo, NSW, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
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15
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Are the MORECare guidelines on reporting of attrition in palliative care research populations appropriate? A systematic review and meta-analysis of randomised controlled trials. BMC Palliat Care 2020; 19:6. [PMID: 31918702 PMCID: PMC6953282 DOI: 10.1186/s12904-019-0506-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/12/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Palliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. The guidance separates attrition into three categories: attrition due to death, illness or at random. The aim of our study is to apply the MORECare classifications on reported attrition rates in trials. METHODS A systematic review was conducted and attrition classifications retrospectively applied. Four databases, EMBASE; Medline, CINHAL and PsychINFO, were searched for randomised controlled trials of palliative care populations from 01.01.2010 to 08.10.2016. This systematic review is part of a larger review looking at recruitment to randomised controlled trials in palliative care, from January 1990 to early October 2016. We ran random-effect models with and without moderators and descriptive statistics to calculate rates of missing data. RESULTS One hundred nineteen trials showed a total attrition of 29% (95% CI 28 to 30%). We applied the MORECare classifications of attrition to the 91 papers that contained sufficient information. The main reason for attrition was attrition due to death with a weighted mean of 31.6% (SD 27.4) of attrition cases. Attrition due to illness was cited as the reason for 17.6% (SD 24.5) of participants. In 50.8% (SD 26.5) of cases, the attrition was at random. We did not observe significant differences in missing data between total attrition in non-cancer patients (26%; 95% CI 18-34%) and cancer patients (24%; 95% CI 20-29%). There was significantly more missing data in outpatients (29%; 95% CI 22-36%) than inpatients (16%; 95% CI 10-23%). We noted increased attrition in trials with longer durations. CONCLUSION Reporting the cause of attrition is useful in helping to understand trial results. Prospective reporting using the MORECare classifications should improve our understanding of future trials.
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Frith P, Sladek R, Woodman R, Effing T, Bradley S, van Asten S, Jones T, Hnin K, Luszcz M, Cafarella P, Eckermann S, Rowett D, Phillips PA. Pragmatic randomised controlled trial of a personalised intervention for carers of people requiring home oxygen therapy. Chron Respir Dis 2020; 17:1479973119897277. [PMID: 31903773 PMCID: PMC6945457 DOI: 10.1177/1479973119897277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We used a pragmatic randomised controlled trial to evaluate a behavioural change strategy targeting carers of chronically hypoxaemic patients using long-term home oxygen therapy. Intervention group carers participated in personalised educational sessions focusing on motivating carers to take actions to assist patients. All patients received usual care. Effectiveness was measured through a composite event of patient survival to hospitalisation, residential care admission or death to 12 months. Secondary outcomes at baseline, 3, 6 and 12 months included carer and patient emotional and physical well-being. No difference between intervention (n = 100) and control (n = 97) patients was found for the composite outcome (hazard ratio (HR) 1.22, 95% confidence interval (CI) = 0.89, 1.68; p = 0.22). Improved fatigue, mastery, vitality and general health occurred in intervention group patients (all p values < 0.05). No benefits were seen in carer outcomes. Mortality was significantly higher in intervention patients (HR = 2.01, 95% CI = 1.00, 4.14; p = 0.05; adjusted for Australia-modified Karnofsky Performance Status), with a significant diagnosis-intervention interaction (p = 0.028) showing higher mortality in patients with COPD (HR 4.26; 95% CI = 1.60, 11.35) but not those with interstitial lung disease (HR 0.83; 95% CI = 0.28, 2.46). No difference was detected in the primary outcome, but patient mortality was higher when carers had received the intervention, especially in the most disabled patients. Trials examining behavioural change interventions in severe disease should stratify for functionality, and both risks and benefits should be independently monitored. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12607000177459).
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Affiliation(s)
- Peter Frith
- College of Medicine & Public Health, Flinders University, Adelaide, Australia.,Health and Alliance for Research in Exercise, Nutrition and Activity (ARENA), School of Health Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Ruth Sladek
- College of Medicine & Public Health, Flinders University, Adelaide, Australia.,Prideaux Centre for Research in Health Professions Education, College of Medicine & Public Health, Flinders University, Adelaide, Australia
| | - Richard Woodman
- Flinders Centre for Epidemiology and Biostatistics, College of Medicine & Public Health, Flinders University, Adelaide, Australia
| | - Tanja Effing
- College of Medicine & Public Health, Flinders University, Adelaide, Australia.,Department of Respiratory and Sleep Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Sandra Bradley
- College of Nursing & Health Sciences, Flinders University, Adelaide, Australia
| | - Suzanne van Asten
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Tina Jones
- Department for Health and Well-being, SA Health, Adelaide, Australia
| | - Khin Hnin
- Adelaide Sleep Health, Southern Adelaide Local Health Network, Adelaide, Australia.,Adelaide Institute for Sleep Health, College of Medicine & Public Health, Flinders University, Adelaide, Australia
| | - Mary Luszcz
- Department of Psychology, College of Education, Psychology & Social Work, Flinders University, Adelaide, Australia
| | - Paul Cafarella
- College of Medicine & Public Health, Flinders University, Adelaide, Australia.,Department of Respiratory and Sleep Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Simon Eckermann
- Australian Health Services Research Institute, University of Wollongong, Wollongong, Australia
| | - Debra Rowett
- Drug and Therapeutics Information Service, Southern Adelaide Local Health Network, Adelaide, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Paddy A Phillips
- College of Medicine & Public Health, Flinders University, Adelaide, Australia.,Department for Health and Well-being, SA Health, Adelaide, Australia
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Woolfield A, Mitchell G, Kondalsamy-Chennakesavan S, Senior H. Predicting Those Who Are at Risk of Dying within Six to Twelve Months in Primary Care: A Retrospective Case–Control General Practice Chart Analysis. J Palliat Med 2019; 22:1417-1424. [DOI: 10.1089/jpm.2018.0562] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anne Woolfield
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Sunshine Coast University Hospital, Caloundra, Australia
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | | | - Hugh Senior
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- College of Health, Massey University, Auckland, New Zealand
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18
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Gallagher C, Rowett D, Nyfort-Hansen K, Simmons S, Brooks AG, Moss JR, Middeldorp ME, Hendriks JM, Jones T, Mahajan R, Lau DH, Sanders P. Patient-Centered Educational Resources for Atrial Fibrillation. JACC Clin Electrophysiol 2019; 5:1101-1114. [DOI: 10.1016/j.jacep.2019.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/19/2019] [Accepted: 08/19/2019] [Indexed: 10/26/2022]
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19
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Liyanage T, Mitchell G, Senior H. Identifying palliative care needs in residential care. Aust J Prim Health 2019; 24:524-529. [PMID: 30423282 DOI: 10.1071/py17168] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 08/19/2018] [Indexed: 12/16/2022]
Abstract
The aim of this study is to determine the accuracy, feasibility and acceptability of the surprise question (SQ) in combination with a clinical prediction tool (Supportive and Palliative Care Indicator Tool (SPICT)) in identifying residents who have palliative care needs in residential aged care facilities (RACFs) in Australia. A prospective cohort study in two RACFs containing both high-level care (including dementia) and low-level care beds. Directors of Nursing screened 187 residents at risk of dying by 12 months using first the SQ, and if positive, then the SPICT. At 12-months follow-up, deaths, hospitalisations, use of palliative care services, end-of-life care and clinical indicators were recorded. The SQ had a sensitivity of 70%, a specificity of 69.6%, a positive predictive value of 40.6% and a negative predictive value of 88.7% for death. All residents identified by the SQ had at least two general indicators of deterioration, while 98.8% had at least one disease-specific indicator on the SPICT. The SPICT marginally increased the ability to identify residents in need of proactive end-of-life planning. A combination of the SQ and the SPICT is effective in predicting palliative care needs in residents of aged care facilities, and may trigger timely care planning.
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Affiliation(s)
- Thilini Liyanage
- School of Medicine, The University of Queensland, 288 Herston Road, Herston, Brisbane, Qld 4006, Australia
| | - Geoffrey Mitchell
- School of Medicine, The University of Queensland, 288 Herston Road, Herston, Brisbane, Qld 4006, Australia
| | - Hugh Senior
- School of Medicine, The University of Queensland, 288 Herston Road, Herston, Brisbane, Qld 4006, Australia
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20
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Hendriks JM, Brooks AG, Rowett D, Moss JR, Gallagher C, Nyfort-Hansen K, Simmons S, Middeldorp ME, Jones T, Thomas G, Lau DH, Sanders P. Home-Based Education and Learning Program for Atrial Fibrillation: Rationale and Design of the HELP-AF Study. Can J Cardiol 2019; 35:846-854. [DOI: 10.1016/j.cjca.2019.03.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/24/2019] [Accepted: 03/24/2019] [Indexed: 11/16/2022] Open
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21
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To THM, Currow DC, Swetenham K, Morgan DD, Tieman J. How Can Activity Monitors Be Used in Palliative Care Patients? J Palliat Med 2019; 22:830-832. [PMID: 30888890 DOI: 10.1089/jpm.2018.0414] [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: 11/12/2022] Open
Abstract
Background: Physical activity in palliative care patients is closely linked to independence, function, carer burden, prognosis, and quality of life. Changes in physical activity can also be related to service provision needs, including requirements for support and prognosis. However, the objective measurement of physical activity is challenging, with options, including self-report, invasive and intensive measures such as calorimetry, or newer options such as pedometers and accelerometers. This latter option is also becoming more viable with the advent of consumer technology driven by the health and exercise industry. Objective: In this article, we highlight our experiences of activity monitoring in palliative care patients as part of telehealth trial. We also highlight the strengths and limitations of activity monitoring in the palliative care population and potential applications. Conclusions: Although the advent of consumer technology for activity measurement makes their use seem attractive in clinical settings for palliative care patients, there are a number of issues that must be considered, in particular the reason for the activity monitoring and associated limitations in the technology.
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Affiliation(s)
- Timothy H M To
- 1 Division of Rehabilitation, Aged Care and Palliative Care, Flinders Medical Centre, Adelaide, Australia.,2 Faculty of Health, University of Technology Sydney, Ultimo, Australia.,3 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - David C Currow
- 2 Faculty of Health, University of Technology Sydney, Ultimo, Australia.,3 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Kate Swetenham
- 4 Southern Adelaide Palliative Services, Adelaide, Australia
| | - Deidre D Morgan
- 3 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Jennifer Tieman
- 3 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
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22
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Philip J, Collins A, Le B, Sundararajan V, Brand C, Hanson S, Emery J, Hudson P, Mileshkin L, Ganiatsas S. A randomised phase II trial to examine feasibility of standardised, early palliative (STEP) care for patients with advanced cancer and their families [ACTRN12617000534381]: a research protocol. Pilot Feasibility Stud 2019; 5:44. [PMID: 30915228 PMCID: PMC6417202 DOI: 10.1186/s40814-019-0424-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 02/24/2019] [Indexed: 11/12/2022] Open
Abstract
Background Current international consensus is that 'early' referral to palliative care services improves cancer patient and family carer outcomes; however, in practice, these referrals are not routine. Uncertainty about the 'best time' to refer has been highlighted as contributing to care variation. Previous work has identified clear disease-specific transition points in the cancer illness which heralded subsequent poor prognosis (less than 6 months) and which, we contest, represent times when palliative care should be routinely introduced as a standardised approach, if not already in place, to maximise patient and carer benefit. This protocol details a trial that will test the feasibility of a novel standardised outpatient model of early palliative care [Standardised Early Palliative Care (STEP Care)] for advanced cancer patients and their family carers, with referrals occurring at the defined disease-specific evidence-based transition points.The aims of this study are to (1) determine the feasibility of conducting a definitive phase 3 randomised trial, which evaluates effectiveness of STEP Care (compared to usual best practice cancer care) for patients with advanced breast or prostate cancer or high grade glioma; (2) examine preliminary efficacy of STEP Care on patient/family caregiver outcomes, including quality of life, mood, symptoms, illness understanding and overall survival; (3) document the impact of STEP Care on quality of end-of-life care; and (4) evaluate the timing of palliative care introduction according to patients, families and health care professionals. Methods Phase 2, multicenter, open-label, parallel-arm, randomised controlled trial (RCT) of STEP Care plus standard best practice cancer care versus standard best practice cancer care alone. Discussion The research will test the feasibility of standardised palliative care introduction based on illness transitions and provide guidance on subsequent development of phase 3 studies of integration. This will directly address the current uncertainty about palliative care timing. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12617000534381.
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Affiliation(s)
- Jennifer Philip
- 1Department of Medicine, University of Melbourne, c/o St Vincent's Hospital, Victoria Pde, Fitzroy, 3065 Australia.,2Palliative Care Service, St Vincent's Hospital Melbourne, Fitzroy, Australia.,3Palliative Care Service, Royal Melbourne Hospital, Parkville, Australia.,4Palliative Care Service, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Anna Collins
- 1Department of Medicine, University of Melbourne, c/o St Vincent's Hospital, Victoria Pde, Fitzroy, 3065 Australia
| | - Brian Le
- 3Palliative Care Service, Royal Melbourne Hospital, Parkville, Australia.,4Palliative Care Service, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Vijaya Sundararajan
- 1Department of Medicine, University of Melbourne, c/o St Vincent's Hospital, Victoria Pde, Fitzroy, 3065 Australia.,5Public Health, La Trobe University, Bundoora, Australia
| | - Caroline Brand
- 6Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Jon Emery
- 8Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Peter Hudson
- 9Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Linda Mileshkin
- 10Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Soula Ganiatsas
- 9Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia
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23
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Boland JW, Allgar V, Boland EG, Kaasa S, Hjermstad MJ, Johnson MJ. Predictors and trajectory of performance status in patients with advanced cancer: A secondary data analysis of the international European Palliative Care Cancer Symptom study. Palliat Med 2019; 33:206-212. [PMID: 30404572 PMCID: PMC6350180 DOI: 10.1177/0269216318811011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND: Performance status, a predictor of cancer survival, and ability to maintain independent living deteriorate in advanced disease. Understanding predictors of performance status trajectory could help identify those at risk of functional deterioration, target support for independent living and reduce service costs. The relationship between symptoms, analgesics and performance status is poorly delineated. AIM: The aim of this study is to determine whether demographics, analgesics, disease characteristics, quality-of-life domains and C-reactive protein predict the trajectory of Karnofsky Performance Status (KPS) in patients with advanced cancer. DESIGN: The study design is the secondary data analysis of the international prospective, longitudinal European Palliative Care Cancer Symptom study (ClinicalTrials.gov: NCT01362816). A multivariable regression model was built for KPS area under the curve per day (AUC). SETTING AND PARTICIPANTS: This included adults with advanced, incurable cancer receiving palliative care, without severe cognitive impairment and who were not imminently dying (n = 1739). RESULTS: The mean daily KPS AUC (n = 1052) was 41.1 (standard deviation = 14.1). Opioids (p < 0.001), co-analgesics (p = 0.023), poorer physical functioning (p < 0.001) and appetite loss (p = 0.009) at baseline were explanatory factors for lower KPS AUC. A subgroup analysis of participants with C-reactive protein data (n = 240) showed that only C-reactive protein (p = 0.040) and physical function (p < 0.001) were associated with lower KPS AUC. CONCLUSION: This study is novel in determining explanatory factors for subsequent functional trajectories in an international dataset and identifying systemic inflammation as a candidate therapeutic target to improve functional performance. The effect of interventions targeting physical function, appetite and inflammation, such as those used for cachexia management, on maintaining functional status in patients with advanced cancer needs to be investigated.
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Affiliation(s)
- Jason W Boland
- 1 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | | | | | - Stein Kaasa
- 4 European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Marianne J Hjermstad
- 4 European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Miriam J Johnson
- 1 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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24
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Malik S, Goldman R, Kevork N, Wentlandt K, Husain A, Merrow N, Le LW, Zimmermann C. Engagement of Primary Care Physicians in Home Palliative Care. J Palliat Care 2018; 32:3-10. [PMID: 28662623 DOI: 10.1177/0825859717706791] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To describe prevalence and characteristics associated with family physician and general practitioner (FP/GP) provision of home palliative care (HPC). METHODS We surveyed FP/GPs in an urban health region of Ontario, Canada, to determine their current involvement in HPC, the nature of services provided, and perceived barriers and enablers. RESULTS A total of 1439 surveys were mailed. Of the 302 FP/GP respondents, 295 provided replies regarding engagement in HPC: 101 of 295 (33%) provided HPC, 76 (26%) were engageable with further support, and 118 (40%) were not engageable regardless of support. The most substantial barrier was time to provide home visits (81%). Engaged FP/GPs were most likely to be working with another physician providing HPC ( P < .0001). Engageable FP/GPs were younger ( P = .007) and placed greater value on improved remuneration ( P < .001) than the other groups. Nonengageable physicians were most likely to view time as a barrier ( P < .0001) and to lack interest in PC ( P = .03). CONCLUSION One-third of FP/GPs provide HPC. A cohort of younger physicians could be engageable with adequate support. Integrated practices including collaboration with specialist PC colleagues should be encouraged and supported.
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Affiliation(s)
- Shiraz Malik
- 1 Department of Family Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Russell Goldman
- 2 Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,3 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nanor Kevork
- 4 Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Kirsten Wentlandt
- 3 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,4 Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Amna Husain
- 2 Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,3 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nancy Merrow
- 5 Orillia Soldiers Memorial Hospital, Orillia, Ontario, Canada
| | - Lisa W Le
- 6 Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- 4 Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,7 Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,8 Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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25
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Coombes JA, Rowett D, Whitty JA, Cottrell WN. Use of a patient-centred educational exchange (PCEE) to improve patient's self-management of medicines after a stroke: a randomised controlled trial study protocol. BMJ Open 2018; 8:e022225. [PMID: 30166304 PMCID: PMC6119418 DOI: 10.1136/bmjopen-2018-022225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION National and international guidelines make recommendations for secondary prevention of stroke including the use of medications. A strategy which engages patients in a conversation to personalise evidence-based educational material (patient-centred educational exchange; PCEE) may empower patients to better manage their medications. METHODS AND ANALYSIS This protocol outlines a non-blinded randomised controlled trial. Consenting patients admitted with a diagnosis of stroke or transient ischaemic attack will be randomised 1:1 to receive either a PCEE composed of two sessions, one at the bedside before discharge and one by telephone at least 10 days after discharge from hospital in addition to usual care (intervention) or usual care alone (control). The primary aim of this study is to determine whether a PCEE improves adherence to antithrombotic, antihypertensive and lipid-lowering medications prescribed for secondary prevention of stroke over the 3 months after discharge, measured using prescription-refill data. Secondary aims include investigation of the impact of the PCEE on adherence over 12 months using prescription-refill data, self-reported medication taking behaviour, self-reported clinical outcomes (blood pressure, cholesterol, adverse medication events and readmission), quality of life, the cost utility of the intervention and changes in beliefs towards medicines and illness. ETHICS AND DISSEMINATION Communication of the trial results will provide evidence to aid clinicians in conversations with patients about medication taking behaviour related to stroke prevention. The targeted audiences will be health practitioners and consumers interested in medication taking behaviour in chronic diseases and in particular those interested in secondary prevention of stroke.The trial has ethics approval from Metro South Human Research Ethics Committee (HREC/15/QPAH/531) and The University of Queensland Institutional Human Research Ethics (2015001612). TRIAL REGISTRATION NUMBER ACTRN12615000888561; Pre-results.
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Affiliation(s)
- Judith Ann Coombes
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Debra Rowett
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
- DATIS, Southern Adelaide Local Health Network, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Jennifer A Whitty
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - W Neil Cottrell
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
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26
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Budhwani S, Wodchis WP, Zimmermann C, Moineddin R, Howell D. Self-management, self-management support needs and interventions in advanced cancer: a scoping review. BMJ Support Palliat Care 2018; 9:12-25. [PMID: 30121581 DOI: 10.1136/bmjspcare-2018-001529] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/29/2018] [Accepted: 07/11/2018] [Indexed: 12/25/2022]
Abstract
Patients with advanced cancer can experience illness trajectories similar to other progressive chronic disease conditions where undertaking self-management (SM) and provision of self-management support (SMS) becomes important. The main objectives of this study were to map the literature of SM strategies and SMS needs of patients with advanced cancer and to describe SMS interventions tested in this patient population. A scoping review of all literature published between 2002 and 2016 was conducted. A total of 11 094 articles were generated for screening from MEDLINE, Embase, PsychINFO, CINAHL and Cochrane Library databases. A final 55 articles were extracted for inclusion in the review. Included studies identified a wide variety of SM behaviours used by patients with advanced cancer including controlling and coping with the physical components of the disease and facilitating emotional and psychosocial adjustments to a life-limiting illness. Studies also described a wide range of SMS needs, SMS interventions and their effectiveness in this patient population. Findings suggest that SMS interventions addressing SMS needs should be based on a sound understanding of the core skills required for effective SM and theoretical and conceptual frameworks. Future research should examine how a patient-oriented SMS approach can be incorporated into existing models of care delivery and the effects of SMS on quality of life and health system utilisation in this population.
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Affiliation(s)
- Suman Budhwani
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada.,Health System Performance Research Network, University of Toronto, Toronto, ON, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada.,Health System Performance Research Network, University of Toronto, Toronto, ON, Canada
| | - Camilla Zimmermann
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Doris Howell
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
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Collins A, Sundararajan V, Burchell J, Millar J, McLachlan SA, Krishnasamy M, Le BH, Mileshkin L, Hudson P, Philip J. Transition Points for the Routine Integration of Palliative Care in Patients With Advanced Cancer. J Pain Symptom Manage 2018; 56:185-194. [PMID: 29608934 DOI: 10.1016/j.jpainsymman.2018.03.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 03/26/2018] [Accepted: 03/27/2018] [Indexed: 10/17/2022]
Abstract
CONTEXT Increasing emphases are being placed on early integration of palliative care for patients with advanced cancers, yet barriers to implementation in clinical practice remain. Criteria to standardize referral have been endorsed, but their application is yet to be tested at the population level. OBJECTIVES This study sought to establish the need for standardized referral by examining current end-of-life care outcomes of decedents with cancer and define transition points within a cancer illness course, which are associated with poor prognosis, whereby palliative care should be routinely introduced to augment clinician-based decision making. METHODS Population cohort study of admitted patients with advanced cancer diagnosed with non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), prostate or breast cancer between 2000 and 2010 in Victoria, Australia, identified from routinely collected, linked, hospital discharge, emergency department, and death registration data. Descriptive statistics described quality indicators for end-of-life care outcomes for decedents. Kaplan-Meier analyses were used to test the predefined transition point that mostly accurately predicted survival of six months or lesser. RESULTS About 46,700 cases (56% females) were admitted with metastatic NSCLC (n = 14,759; 31.6%), SCLC (n = 2932; 6%), prostate (n = 9445; 20.2%), and breast cancer (n = 19,564; 41.9%). Of the 29,680 decedents, most (80%) died in hospital, had suboptimal end-of-life care outcomes (83%), and 59% received a palliative approach to care, a median of 27 days before death. Transition points in the cancer illness course of all cases were identified as first admission with any metastatic disease (NSCLC: 3.8 months [interquartile range {IQR} 1.1, 16.0]; n = 14,666; and SCLC: 4.2 months [IQR 1.0, 10.6]; n = 2914); first multiday admission with any metastatic disease (prostate: 6.0 months [IQR 1.3, 26.4]; n = 7174); and first multiday admission with at least one visceral metastatic site (breast: 6.0 months [IQR 1.2, 29.8]; n = 7120). CONCLUSION Despite calls for integrated palliative care, this occurs late or not at all for many patients with cancer. Our findings demonstrate the application of targeted cancer-specific transition points to trigger integration of palliative care as a standard part of quality oncological care and augment clinician-based referral in routine clinical practice.
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Affiliation(s)
- Anna Collins
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; VCCC Palliative Medicine Research Group, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.
| | - Vijaya Sundararajan
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jodie Burchell
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jeremy Millar
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Sue-Anne McLachlan
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Medical Oncology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Meinir Krishnasamy
- Department of Nursing, University of Melbourne, Melbourne, Victoria, Australia
| | - Brian H Le
- Palliative Care Service, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Linda Mileshkin
- Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Peter Hudson
- Centre for Palliative Care, St Vincent's Hospital Melbourne & University of Melbourne, Melbourne, Victoria, Australia; Vrije University, Brussel, Belgium
| | - Jennifer Philip
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; VCCC Palliative Medicine Research Group, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
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Mitchell GK, Senior HE, Rhee JJ, Ware RS, Young S, Teo PC, Murray S, Boyd K, Clayton JM. Using intuition or a formal palliative care needs assessment screening process in general practice to predict death within 12 months: A randomised controlled trial. Palliat Med 2018; 32:384-394. [PMID: 28452570 DOI: 10.1177/0269216317698621] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Population ageing will lead to more deaths with an uncertain trajectory. Identifying patients at risk of dying could facilitate more effective care planning. AIM To determine whether screening for likely death within 12 months is more effective using screening tools or intuition. DESIGN Randomised controlled trial of screening tools (Surprise Question plus the Supportive and Palliative Care Indicators Tool for Surprise Question positive patients) to predict those at risk of death at 12 months compared with unguided intuition (clinical trials registry: ACTRN12613000266763). SETTING/PARTICIPANTS Australian general practice. A total of 30 general practitioners (screening tool = 12, intuition = 18) screened all patients ( n = 4365) aged ≥70 years seen at least once in the last 2 years. RESULTS There were 142 deaths (screening tool = 3.1%, intuition = 3.3%; p = 0.79). General practitioners identified more at risk of dying using Surprise Question (11.8%) than intuition (5.4%; p = 0.01), but no difference with Surprise Question positive then Supportive and Palliative Care Indicators Tool (5.1%; p = 0.87). Surprise Question positive predicted more deaths (53.2%, intuition = 33.7%; p = 0.001), but Surprise Question positive/Supportive and Palliative Care Indicators Tool predictions were similar (5.1%; p = 0.87 vs intuition). There was no difference in proportions correctly predicted to die (Surprise Question = 1.6%, intuition = 1.1%; p = 0.156 and Surprise Question positive/Supportive and Palliative Care Indicators Tool = 1.1%; p = 0.86 vs intuition). Screening tool had higher sensitivity and lower specificity than intuition, but no difference in positive or negative predictive value. CONCLUSION Screening tool was better at predicting actual death than intuition, but with a higher false positive rate. Both were similarly effective at screening the whole cohort for death. Screening for possible death is not the best option for initiating end-of-life planning: recognising increased burden of illness might be a better trigger.
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Affiliation(s)
- Geoffrey K Mitchell
- 1 Faculty of Medicine of Medicine, University of Queensland, Herston, QLD, Australia
| | - Hugh E Senior
- 1 Faculty of Medicine of Medicine, University of Queensland, Herston, QLD, Australia.,2 College of Health, Massey University, Auckland, New Zealand
| | - Joel J Rhee
- 3 HammondCare Centre for Positive Ageing and Care, Sydney, NSW, Australia.,4 School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Robert S Ware
- 5 Menzies Health Institute Queensland, Griffith University, Nathan, QLD, Australia
| | - Sharleen Young
- 1 Faculty of Medicine of Medicine, University of Queensland, Herston, QLD, Australia.,6 West Moreton Hospital and Health Service, Ipswich, QLD, Australia
| | - Patrick Ck Teo
- 4 School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Scott Murray
- 7 Primary Palliative Care Research Group, The Usher Institute for Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Kirsty Boyd
- 7 Primary Palliative Care Research Group, The Usher Institute for Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Josephine M Clayton
- 8 HammondCare Palliative and Supportive Care Service, Greenwich Hospital, Greenwich, NSW, Australia.,9 School of Medicine, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
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29
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Mitchell GK, Senior HE, Johnson CE, Fallon-Ferguson J, Williams B, Monterosso L, Rhee JJ, McVey P, Grant MP, Aubin M, Nwachukwu HTG, Yates PM. Systematic review of general practice end-of-life symptom control. BMJ Support Palliat Care 2018; 8:411-420. [DOI: 10.1136/bmjspcare-2017-001374] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 12/15/2017] [Accepted: 12/20/2017] [Indexed: 11/04/2022]
Abstract
BackgroundEnd of life care (EoLC) is a fundamental role of general practice, which will become more important as the population ages. It is essential that general practice’s role and performance of at the end of life is understood in order to maximise the skills of the entire workforce.ObjectiveTo provide a comprehensive description of the role and performance of general practitioners (GPs) and general practice nurses (GPNs) in EoLC symptom control.MethodSystematic literature review of papers from 2000 to 2017 were sought from Medline, PsycINFO, Embase, Joanna Briggs Institute and Cochrane databases.ResultsFrom 6209 journal articles, 46 papers reported GP performance in symptom management. There was no reference to the performance of GPNs in any paper identified. Most GPs expressed confidence in identifying EoLC symptoms. However, they reported lack of confidence in providing EoLC at the beginning of their careers, and improvements with time in practice. They perceived emotional support as being the most important aspect of EoLC that they provide, but there were barriers to its provision. GPs felt most comfortable treating pain, and least confident with dyspnoea and depression. Observed pain management was sometimes not optimal. More formal training, particularly in the use of opioids was considered important to improve management of both pain and dyspnoea.ConclusionsIt is essential that GPs receive regular education and training, and exposure to EoLC from an early stage in their careers to ensure skill and confidence. Research into the role of GPNs in symptom control needs to occur.
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Schenker Y, Bahary N, Claxton R, Childers J, Chu E, Kavalieratos D, King L, Lembersky B, Tiver G, Arnold RM. A Pilot Trial of Early Specialty Palliative Care for Patients with Advanced Pancreatic Cancer: Challenges Encountered and Lessons Learned. J Palliat Med 2018; 21:28-36. [PMID: 28772092 PMCID: PMC5757080 DOI: 10.1089/jpm.2017.0113] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients with advanced pancreatic cancer suffer from high morbidity and mortality. Specialty palliative care may improve quality of life. OBJECTIVE Assess the feasibility, acceptability, and perceived effectiveness of early specialty physician-led palliative care for patients with advanced pancreatic cancer and their caregivers. DESIGN A mixed-methods pilot randomized controlled trial in which patient-caregiver pairs were randomized (2:1) to receive specialty palliative care, in addition to standard oncology care versus standard oncology care alone. SETTING/SUBJECTS At a National Cancer Institute-designated comprehensive cancer center in Western Pennsylvania, 30 patients with advanced pancreatic adenocarcinoma and their caregivers (N = 30), oncologists (N = 4), and palliative care physicians (N = 3) participated. MEASUREMENTS Feasibility (enrollment, three-month outcome-assessment, and intervention completion rates), acceptability, and perceived effectiveness (process interviews with patients, caregivers, and physicians). RESULTS Consent:approach rate was 49%, randomized:consent rate 55%, and three-month outcome assessment rate 75%. Two patients and three caregivers withdrew early. The three-month mortality rate was 13%. Patients attended a mean of 1.3 (standard deviation 1.1) palliative care visits during the three-month period. Positive experiences with palliative care included receiving emotional support and symptom management. Negative experiences included inconvenience, long travel times, spending too much time at the cancer center, and no perceived palliative care needs. Physicians suggested embedding palliative care within oncology clinics, tailoring services to patient needs, and facilitating face-to-face communication between oncologists and palliative physicians. CONCLUSIONS A randomized trial of early palliative care for advanced pancreatic cancer did not achieve feasibility goals. Integrating palliative care within oncology clinics may increase acceptability and perceived effectiveness.
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Affiliation(s)
- Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nathan Bahary
- Division of Hematology Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Cancer Centers, Pittsburgh, Pennsylvania
| | - Rene Claxton
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward Chu
- Division of Hematology Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Linda King
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Greer Tiver
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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31
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Phongtankuel V, Meador L, Adelman RD, Roberts J, Henderson CR, Mehta SS, del Carmen T, Reid M. Multicomponent Palliative Care Interventions in Advanced Chronic Diseases: A Systematic Review. Am J Hosp Palliat Care 2018; 35:173-183. [PMID: 28273750 PMCID: PMC5879777 DOI: 10.1177/1049909116674669] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Many patients live with serious chronic or terminal illnesses. Multicomponent palliative care interventions have been increasingly utilized in patient care; however, it is unclear what is being implemented and who is delivering these interventions. OBJECTIVES To (1) describe the delivery of multicomponent palliative care interventions, (2) characterize the disciplines delivering care, (3) identify the components being implemented, and (4) analyze whether the number of disciplines or components being implemented are associated with positive outcomes. DESIGN Systematic review. STUDY SELECTION English-language articles analyzing multicomponent palliative care interventions. OUTCOMES MEASURED Delivery of palliative interventions by discipline, components of palliative care implemented, and number of positive outcomes (eg, pain, quality of life). RESULTS Our search strategy yielded 71 articles, which detailed 64 unique multicomponent palliative care interventions. Nurses (n = 64, 88%) were most often involved in delivering care, followed by physicians (n = 43, 67%), social workers (n = 33, 52%), and chaplains (n = 19, 30%). The most common palliative care components patients received were symptom management (n = 56, 88%), psychological support/counseling (n = 52, 81%), and disease education (n = 48, 75%). Statistical analysis did not uncover an association between number of disciplines or components and positive outcomes. CONCLUSIONS While there has been growth in multicomponent palliative care interventions over the past 3 decades, important aspects require additional study such as better inclusion of key groups (eg, chronic obstructive pulmonary disease, end-stage renal disease, minorities, older adults); incorporating core components of palliative care (eg, interdisciplinary team, integrating caregivers, providing spiritual support); and developing ways to evaluate the effectiveness of interventions that can be readily replicated and disseminated.
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Affiliation(s)
- Veerawat Phongtankuel
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - Lauren Meador
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - Ronald D. Adelman
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | | | | | - Sonal S. Mehta
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - Tessa del Carmen
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - M.C. Reid
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
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32
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Gomes B, de Brito M, Sarmento VP, Yi D, Soares D, Fernandes J, Fonseca B, Gonçalves E, Ferreira PL, Higginson IJ. Valuing Attributes of Home Palliative Care With Service Users: A Pilot Discrete Choice Experiment. J Pain Symptom Manage 2017; 54:973-985. [PMID: 28797859 DOI: 10.1016/j.jpainsymman.2017.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/24/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT Discrete choice experiment (DCE) is a quantitative method that helps determine which service attributes are most valued by people and consequently improve their well-being. OBJECTIVES The objective of this study was to test a new DCE on home palliative care (HPC). METHODS Cross-sectional survey using the DCE method with adult patients and their family caregivers, users of three HPC services in Portugal. Service attributes were based on a Cochrane review, a meta-ethnography, and the few existing DCEs on HPC: 1) team's availability, 2) support for family caregivers, 3) homecare support, 4) information and planning, and 5) waiting time. The experimental design consisted in three blocks of eight choice sets where participants chose between two service alternatives that combined different levels of each attribute. We piloted the DCE using cognitive interviewing. Interviews were analyzed for difficulties using Tourangeau's model of information processing. RESULTS The DCE was conducted with 21 participants of 37 eligible (10 patients with median Palliative Performance Scale score = 45, 11 caregivers). Most participants found the DCE easy (median 2 from 1 to 5), although two patients did not finish the exercise. Key difficulties related to comprehension (e.g., waiting time sometimes understood as response time for visit instead of time from referral to care start) and judgment (e.g., indecision due to similar service alternatives). CONCLUSION The DCE method is feasible and acceptable but not all patients are able to participate. In the main study phase, we will give more attention to the explanation of the waiting time attribute.
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Affiliation(s)
- Barbara Gomes
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal; Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom.
| | - Maja de Brito
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Vera P Sarmento
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Duarte Soares
- Palliative Care Department, Northeast Local Health Unit (Unidade Local de Saúde do Nordeste-ULSNE), Bragança, Portugal
| | - Jacinta Fernandes
- Home Palliative Care Unit Planalto Mirandês, Northeast Local Health Unit (Unidade Local de Saúde do Nordeste-ULSNE), Miranda do Douro, Portugal
| | - Bruno Fonseca
- Palliative Care Team, Matosinhos Local Health Unit (Unidade Local de Saúde de Matosinhos-ULSM), Matosinhos, Portugal
| | - Edna Gonçalves
- Palliative Care Service, São João Hospital Centre (Centro Hospitalar de São João-CHSJ), Porto, Portugal
| | - Pedro L Ferreira
- Centre for Health Studies and Research of the University of Coimbra, Faculty of Economics, Coimbra, Portugal
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
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Smith CB, Phillips T, Smith TJ. Using the New ASCO Clinical Practice Guideline for Palliative Care Concurrent With Oncology Care Using the TEAM Approach. Am Soc Clin Oncol Educ Book 2017; 37:714-723. [PMID: 28561696 DOI: 10.1200/edbk_175474] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Palliative care alongside usual oncology care is now recommended by ASCO as the standard of care for any patient with advanced cancer on the basis of multiple randomized trials that show better results with concurrent care than with usual oncology care. Some benefits include better quality of life, better symptom management, reduced anxiety and depression, less caregiver distress, more accordance of care with the wishes of the patient, and less aggressive end-of-life care. Several studies show a survival advantage of several months, and many show considerable cost savings: better care at an affordable cost. However, there are not enough palliative care specialists available, so oncologists must practice exemplary primary palliative care. Protocols used in the clinical trials, similar to those designed for new chemotherapy agents, help oncologists use the TEAM approach of extra time, typically an hour a month spent with the palliative care team; education, especially about prognostic awareness and realistic options, which include formal setting of goals of care and discussion of advance directives; formal assessments for symptoms and for spiritual and psychosocial health; and management by an interdisciplinary team. These are all potentially accomplished by an oncology practice to replicate the services provided by concurrent palliative care.
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Affiliation(s)
- Cardinale B Smith
- From the Tisch Cancer Institute, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; CHRISTUS St. Frances Cabrini Hospital, Alexandria, LA; Harry J. Duffey Family Patient and Family Services Program, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Tanyanika Phillips
- From the Tisch Cancer Institute, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; CHRISTUS St. Frances Cabrini Hospital, Alexandria, LA; Harry J. Duffey Family Patient and Family Services Program, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Thomas J Smith
- From the Tisch Cancer Institute, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; CHRISTUS St. Frances Cabrini Hospital, Alexandria, LA; Harry J. Duffey Family Patient and Family Services Program, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, MD
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Bakitas MA, El-Jawahri A, Farquhar M, Ferrell B, Grudzen C, Higginson I, Temel JS, Zimmermann C, Smith TJ. The TEAM Approach to Improving Oncology Outcomes by Incorporating Palliative Care in Practice. J Oncol Pract 2017; 13:557-566. [DOI: 10.1200/jop.2017.022939] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Palliative care (PC) concurrent with usual oncology care is now the standard of care that is recommended for any patient with advanced cancer to begin within 8 weeks of diagnosis on the basis of evidence-driven national clinical practice guidelines; however, there are not enough interdisciplinary palliative care teams to provide such care. How and what can an oncology office incorporate into usual care, borrowing the tools used in PC randomized clinical trials (RCTs), to improve care for patients and their caregivers? We reviewed the multiple RCTs for common practical elements and identified methods and techniques that oncologists can use to deliver some parts of concurrent interdisciplinary PC. We recommend the standardized assessment of patient-reported outcomes, including the evaluation of symptoms with such tools as the Edmonton or Memorial Symptom Assessment Scales, spirituality with the FICA Spiritual History Tool or similar questions, and psychosocial distress with the Distress Thermometer. All patients should be assessed for how they prefer to receive information, their current understanding of their situation, and if they have considered some advance care planning. Approximately 1 hour of additional time with the patient is required each month. If the oncologist does not have established ties with spiritual care and social work, he or she should establish these relationships for counseling as required. Caregivers should be asked about coping and support needs. Oncologists can adapt PC techniques to achieve results that are similar to those in the RCTs of PC plus usual care compared with usual care alone. This is comparable to using data from RCTs of trastuzamab or placebo, adopting what was used in the RCTs without modification or dilution.
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Affiliation(s)
- Marie A. Bakitas
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Areej El-Jawahri
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Morag Farquhar
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Betty Ferrell
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Corita Grudzen
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Irene Higginson
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Jennifer S. Temel
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Camilla Zimmermann
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Thomas J. Smith
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
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Morgan DD, Swetenham K, To THM, Currow DC, Tieman JJ. Telemonitoring via Self-Report and Video Review in Community Palliative Care: A Case Report. Healthcare (Basel) 2017; 5:healthcare5030051. [PMID: 28858221 PMCID: PMC5618179 DOI: 10.3390/healthcare5030051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/09/2017] [Accepted: 08/24/2017] [Indexed: 11/16/2022] Open
Abstract
Continuous monitoring and management of a person's symptoms and performance status are critical for the delivery of effective palliative care. This monitoring occurs routinely in inpatient settings; however, such close evaluation in the community has remained elusive. Patient self-reporting using telehealth offers opportunities to identify symptom escalation and functional decline in real time, and facilitate timely proactive management. We report the case of a 57-year-old man with advanced non-small cell lung cancer who participated in a telehealth trial run by a community palliative care service. This gentleman was able to complete self-reporting of function and symptoms via iPad although at times he was reticent to do so. Self-reporting was perceived as a means to communicate his clinical needs without being a bother to the community palliative care team. He also participated in a videoconference with clinical staff from the community palliative care service and his General Practitioner. Videoconferencing with the nurse and GP was highly valued as an effective way to communicate and also because it eliminated the need for travel. This case report provides important information about the feasibility and acceptability of palliative care telehealth as a way to better manage clinical care in a community setting.
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Affiliation(s)
- Deidre D Morgan
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Bedford Park, Adelaide 5001, Australia.
| | - Kate Swetenham
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Bedford Park, Adelaide 5001, Australia.
- Southern Adelaide Palliative Services, Daw Park, Adelaide 5041, Australia.
| | - Timothy H M To
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Bedford Park, Adelaide 5001, Australia.
- Southern Adelaide Palliative Services, Daw Park, Adelaide 5041, Australia.
| | - David C Currow
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Bedford Park, Adelaide 5001, Australia.
| | - Jennifer J Tieman
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Bedford Park, Adelaide 5001, Australia.
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Agar M, Luckett T, Luscombe G, Phillips J, Beattie E, Pond D, Mitchell G, Davidson PM, Cook J, Brooks D, Houltram J, Goodall S, Chenoweth L. Effects of facilitated family case conferencing for advanced dementia: A cluster randomised clinical trial. PLoS One 2017; 12:e0181020. [PMID: 28786995 PMCID: PMC5546584 DOI: 10.1371/journal.pone.0181020] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/15/2017] [Indexed: 12/01/2022] Open
Abstract
Background Palliative care planning for nursing home residents with advanced dementia is often suboptimal. This study compared effects of facilitated case conferencing (FCC) with usual care (UC) on end-of-life care. Methods A two arm parallel cluster randomised controlled trial was conducted. The sample included people with advanced dementia from 20 Australian nursing homes and their families and professional caregivers. In each intervention nursing home (n = 10), Palliative Care Planning Coordinators (PCPCs) facilitated family case conferences and trained staff in person-centred palliative care for 16 hours per week over 18 months. The primary outcome was family-rated quality of end-of-life care (End-of-Life Dementia [EOLD] Scales). Secondary outcomes included nurse-rated EOLD scales, resident quality of life (Quality of Life in Late-stage Dementia [QUALID]) and quality of care over the last month of life (pharmacological/non-pharmacological palliative strategies, hospitalization or inappropriate interventions). Results Two-hundred-eighty-six people with advanced dementia took part but only 131 died (64 in UC and 67 in FCC which was fewer than anticipated), rendering the primary analysis under-powered with no group effect seen in EOLD scales. Significant differences in pharmacological (P < 0.01) and non-pharmacological (P < 0.05) palliative management in last month of life were seen. Intercurrent illness was associated with lower family-rated EOLD Satisfaction with Care (coefficient 2.97, P < 0.05) and lower staff-rated EOLD Comfort Assessment with Dying (coefficient 4.37, P < 0.01). Per protocol analyses showed positive relationships between EOLD and staff hours to bed ratios, proportion of residents with dementia and staff attitudes. Conclusion FCC facilitates a palliative approach to care. Future trials of case conferencing should consider outcomes and processes regarding decision making and planning for anticipated events and acute illness. Trial registration Australian New Zealand Clinical Trial Registry ACTRN12612001164886
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Affiliation(s)
- Meera Agar
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales (NSW), Australia
- South Western Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia
- Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
- Improving Palliative Care through Clinical Trials (ImPaCCT), Sydney, NSW, Australia
| | - Tim Luckett
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales (NSW), Australia
- * E-mail:
| | - Georgina Luscombe
- Sydney Medical School, The University of Sydney, Ultimo, NSW, Australia
| | - Jane Phillips
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales (NSW), Australia
| | - Elizabeth Beattie
- School of Nursing, Queensland University of Technology, Herston, Queensland (QLD), Australia
| | - Dimity Pond
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Geoffrey Mitchell
- Faculty of Medicine, The University of Queensland, St Lucia, QLD, Australia
| | - Patricia M. Davidson
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales (NSW), Australia
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Janet Cook
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales (NSW), Australia
| | - Deborah Brooks
- School of Nursing, Queensland University of Technology, Herston, Queensland (QLD), Australia
| | - Jennifer Houltram
- Centre for Health Research and Evaluation (CHERE), Faculty of Business, UTS, Haymarket, NSW, Australia
| | - Stephen Goodall
- Centre for Health Research and Evaluation (CHERE), Faculty of Business, UTS, Haymarket, NSW, Australia
| | - Lynnette Chenoweth
- Centre for Healthy Brain Ageing, University of New South Wales, Randwick, NSW, Australia
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Abstract
Current trends in population ageing show that, in the near future, while more people will live longer, more will also die at any one time. Health systems, as well as individual practitioners, are only just becoming aware of the extent of this problem. Health systems will have to rapidly change practice to manage the number of people dying in the coming years, many with complex multimorbid conditions. The changes involved should include a personal recognition by all health professionals of their role in caring for the dying, and healthcare education must include end-of-life care management as part of the core curriculum. Further, health systems must improve integration between primary care and specialist clinicians to ensure the burden is shared efficiently across the system. Finally, it should be recognised that end-of-life care is not terminal care, but should be anticipated months or sometimes years ahead through advance care planning for known future complications by the patient's clinical team, as well as by patients and their main carers, to manage crises as they ariserather than react to them once they arise.Please see related article: https://bmcmedicine.biomedcentral.com/articles/ 10.1186/s12916-017-0860-2 .
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Affiliation(s)
- Geoffrey Mitchell
- Faculty of Medicine,University of Queensland, Herston Road, Herston, 4006, Australia.
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Reeve R, Srasuebkul P, Langton JM, Haas M, Viney R, Pearson SA. Health care use and costs at the end of life: a comparison of elderly Australian decedents with and without a cancer history. BMC Palliat Care 2017; 17:1. [PMID: 28637450 PMCID: PMC5480123 DOI: 10.1186/s12904-017-0213-0] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is limited population-level research on end-of-life care in Australia that considers health care use and costs across hospital and community sectors. The aim of this study was to quantify health care use and costs in the last 6 months of life in a cohort of elderly Australian decedents and to examine the factors associated with end-of-life resource use and costs. METHODS A retrospective cohort study using routinely collected health data from Australian Government Department of Veterans' Affairs clients. The study included two cohorts of elderly Australians who died between 2005 and 2009; one cohort with a recorded cancer diagnosis and a comparison cohort with no evidence of a cancer history. We examined hospitalisations, emergency department (ED) visits, prescription drugs, clinician visits, pathology, and procedures and associated costs in the last 6 months of life. We used negative binominal regression to explore factors associated with health service use and costs. RESULTS The cancer cohort had significantly higher rates of health service use and 27% higher total health care costs than the comparison cohort; in both cohorts, costs were driven primarily by hospitalisations. Older age was associated with lower costs and those who died in residential aged care incurred half the costs of those who died in hospital. CONCLUSIONS The results suggest differences in end-of-life care pathways dependent on patient factors, with younger, community-dwelling patients and those with a history of cancer incurring significantly greater costs. There is a need to examine whether the investment in end-of-life care meets patient and societal needs.
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Affiliation(s)
- Rebecca Reeve
- Centre for Health Economics Research & Evaluation, University of Technology Sydney, PO Box 123 Broadway, Sydney, NSW 2007 Australia
- Centre for Social Impact, UNSW Australia, Sydney, NSW 2000 Australia
| | - Preeyaporn Srasuebkul
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006 Australia
- Department of Developmental Disability Neuropsychiatry, Faculty of Medicine, UNSW Australia, Sydney, NSW 2052 Australia
| | - Julia M. Langton
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006 Australia
- Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, BC V6T 1Z3 Canada
| | - Marion Haas
- Centre for Health Economics Research & Evaluation, University of Technology Sydney, PO Box 123 Broadway, Sydney, NSW 2007 Australia
| | - Rosalie Viney
- Centre for Health Economics Research & Evaluation, University of Technology Sydney, PO Box 123 Broadway, Sydney, NSW 2007 Australia
| | - Sallie-Anne Pearson
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006 Australia
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Australia, Sydney, Australia
| | - On behalf of the EOL-CC study authors
- Centre for Health Economics Research & Evaluation, University of Technology Sydney, PO Box 123 Broadway, Sydney, NSW 2007 Australia
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006 Australia
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Australia, Sydney, Australia
- Centre for Social Impact, UNSW Australia, Sydney, NSW 2000 Australia
- Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, BC V6T 1Z3 Canada
- Department of Developmental Disability Neuropsychiatry, Faculty of Medicine, UNSW Australia, Sydney, NSW 2052 Australia
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Quality of missing data reporting and handling in palliative care trials demonstrates that further development of the CONSORT statement is required: a systematic review. J Clin Epidemiol 2017; 88:81-91. [PMID: 28532739 PMCID: PMC5590708 DOI: 10.1016/j.jclinepi.2017.05.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 02/23/2017] [Accepted: 05/15/2017] [Indexed: 12/25/2022]
Abstract
Objectives Assess (i) the quality of reporting and handling of missing data (MD) in palliative care trials, (ii) whether there are differences in the reporting of criteria specified by the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement compared with those not specified, and (iii) the association of the reporting of MD with journal impact factor and CONSORT endorsement status. Study Design and Setting Systematic review of palliative care randomized controlled trials. CENTRAL, MEDLINE, and EMBASE (2009–2014) were searched. Results One hundred and eight trials (15,560 participants) were included. MD was incompletely reported and not handled in accordance with current guidance. Reporting criteria specified by the CONSORT statement were better reported than those not specified (participant flow, 69%; number of participants not included in the primary outcome analysis, 94%; and the reason for MD, 71%). However, MD in items contributing to scale summaries (10%) and secondary outcomes (9%) were poorly reported, so the proportion of MD stated is likely to be an underestimate. The reason for MD provided was unclear for 54% of participants and only 16% of trials with MD reported a MD sensitivity analysis. The odds of reporting most of the MD and other risk of bias reporting criteria were increased as the journal impact factor increased and in journals that endorsed the CONSORT statement. Conclusion Further development of the CONSORT MD reporting guidance is likely to improve the quality of reporting. Reporting recommendations are provided.
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Mazza D, Mitchell G. Cancer, ageing, multimorbidity and primary care. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28497470 DOI: 10.1111/ecc.12717] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2017] [Indexed: 11/27/2022]
Abstract
Cancer care is complex, and made more so by multimorbidity and ageing. Multimorbidity affects all stages of cancer care from prevention and early detection through to end of life care. The effectiveness of cancer treatments in multimorbid patients may not be understood, as many conditions common in older people may be exclusion criteria in oncology clinical trials. The interaction between pre-existing physical capacity, multiple medical conditions and ageing can delay diagnosis, impact on treatments, complicate survivor care, and impact on decisions about starting and ceasing treatments. General Practitioners (GPs) manages multimorbidity routinely, yet the GP role in comprehensive cancer care is limited. Integration of GP management of multimorbidity in conjunction with oncology services should improve patient outcomes. Integration of care for these patients can educate patients on the minimisation of multimorbidity, develop personalised screening plans and contribute to the wholistic management of people in the surveillance period. GPs should have a major role in end of life care. Integration of general practice and oncology should benefit patient care.
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Affiliation(s)
- D Mazza
- School of Primary Care and Allied Health, Monash University, Notting Hill, Vic., Australia
| | - G Mitchell
- Primary Care Clinical Unit, The University of Queensland Faculty of Medicine, Royal Brisbane & Women's Hospital, Herston, Qld, Australia
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Carmont SA, Mitchell G, Senior H, Foster M. Systematic review of the effectiveness, barriers and facilitators to general practitioner engagement with specialist secondary services in integrated palliative care. BMJ Support Palliat Care 2017; 8:385-399. [PMID: 28196828 DOI: 10.1136/bmjspcare-2016-001125] [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: 02/07/2016] [Revised: 12/08/2016] [Accepted: 01/19/2017] [Indexed: 11/03/2022]
Abstract
The general practitioner (GP) has a critical role in an integrated model of palliative care as they often know the patient and carer well, are experts in generalist care and have knowledge of health and social services in the community. Specialist palliative services have insufficient capacity to meet demand and those with non-cancer terminal conditions and those from rural and remote areas are underserved. Research has focused on improving access to palliative care by engaging the GP with specialist secondary services in integrated palliative care. OBJECTIVES (1) Evaluate the effectiveness of interventions designed to engage GPs and specialist secondary services in integrated palliative care; and (2) identify the personal, system and structural barriers and facilitators to integrated palliative care. METHOD MEDLINE, EMBASE and CINAHL were searched. Any study of a service that engaged the GP with specialist secondary services in the provision of palliative care was included. GP engagement was defined as any organised cooperation between the GP and specialist secondary services in the care of the patient including shared consultations, case conferences that involved at least both the GP and the specialist clinician and/or other secondary services, and/or any formal shared care arrangements between the GP and specialist services. The specialist secondary service is either a specialist palliative service or a service providing specialist care to a palliative population. A narrative framework was used to describe the findings. RESULTS 17 studies were included. There is some evidence that integrated palliative care can reduce hospitalisations and maintain functional status. There are substantial barriers to providing integrated care. Principles and facilitators of the provision of integrated palliative care are discussed. CONCLUSIONS This is an emerging field and further research is required assessing the effectiveness of different models of integrated palliative care.
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Affiliation(s)
- Sue-Ann Carmont
- The University of Queensland, Brisbane, Queensland, Australia
| | | | - Hugh Senior
- The University of Queensland, Brisbane, Queensland, Australia.,Massey University, Auckland, New Zealand
| | - Michele Foster
- The University of Queensland, Brisbane, Queensland, Australia.,Griffith University, Brisbane, Queensland, Australia
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To THM, Tait P, Morgan DD, Tieman JJ, Crawford G, Michelmore A, Currow DC, Swetenham K. Case conferencing for palliative care patients – a survey of South Australian general practitioners. Aust J Prim Health 2017; 23:458-463. [DOI: 10.1071/py16001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 06/15/2017] [Indexed: 11/23/2022]
Abstract
Benefits of case conferencing for people with palliative care needs between a general practitioner, the person and other key participants include improving communication, advance care planning, coordination of care, clarifying goals of care and support for patient, families and carers. Despite a growing evidence base for the benefits, the uptake of case conferencing has been limited in South Australia. The aim of this study is to explore the beliefs and practice of South Australian general practitioners towards case conferencing for people with palliative care needs. Using an online survey, participants were asked about demographics, attitudes towards case conferencing and details about their most recent case conference for a person with palliative care needs. Responses were received from 134 general practitioners (response rate 11%). In total, 80% valued case conferencing for people with palliative care needs; however, <25% had been involved in case conferencing in the previous 2years. The major barrier was time to organise and coordinate case conferences. Enablers included general practitioner willingness or interest, strong relationship with patient, specialist palliative care involvement and assistance with organisation. Despite GPs’ beliefs of the benefits of case conferencing, the barriers remain significant. Enabling case conferencing will require support for organisation of case conferences and review of Medicare Benefits Schedule criteria for reimbursement.
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Isenberg SR, Aslakson RA, Smith TJ. Implementing Evidence-Based Palliative Care Programs and Policy for Cancer Patients: Epidemiologic and Policy Implications of the 2016 American Society of Clinical Oncology Clinical Practice Guideline Update. Epidemiol Rev 2017; 39:123-131. [PMID: 28472313 PMCID: PMC5858032 DOI: 10.1093/epirev/mxw002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2016] [Indexed: 12/25/2022] Open
Abstract
The American Society of Clinical Oncology (ASCO) recently convened an Ad Hoc Palliative Care Expert Panel to update a 2012 provisional clinical opinion by conducting a systematic review of clinical trials in palliative care in oncology. The key takeaways from the updated ASCO clinical practice guidelines (CPGs) are that more people should be referred to interdisciplinary palliative care teams and that more palliative care specialists and palliative care-trained oncologists are needed to meet this demand. The following summary statement is based on multiple randomized clinical trials: "Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs" (J Clin Oncol. 2017;35(1):96). This paper addresses potential epidemiologic and policy interpretations and implications of the ASCO CPGs. Our review of the CPGs demonstrates that to have clinicians implement these guidelines, there is a need for support from stakeholders across the health-care continuum, health system and institutional change, and changes in health-care financing. Because of rising costs and the need to improve value, the need for coordinated care, and change in end-of-life care patterns, many of these changes are already underway.
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Affiliation(s)
- Sarina R Isenberg
- Department of Health, Behavior, and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rebecca A Aslakson
- Department of Health, Behavior, and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Acute and Chronic Care, The Johns Hopkins School of Nursing, Baltimore, Maryland
- Departments of Oncology and Medicine and the Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Comprehensive Cancer Center, The Johns Hopkins Hospital, Baltimore, Maryland
- the Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland
| | - Thomas J Smith
- Departments of Oncology and Medicine and the Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Tieman JJ, Swetenham K, Morgan DD, To TH, Currow DC. Using telehealth to support end of life care in the community: a feasibility study. BMC Palliat Care 2016; 15:94. [PMID: 27855681 PMCID: PMC5114812 DOI: 10.1186/s12904-016-0167-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 11/09/2016] [Indexed: 11/25/2022] Open
Abstract
Background Telehealth is being used increasingly in providing care to patients in the community setting. Telehealth enhanced service delivery could offer new ways of managing load and care prioritisation for palliative care patients living in the community. The study assesses the feasibility of a telehealth-based model of service provision for community based palliative care patients, carers and clinicians. Methods This study was a prospective cohort study of a telehealth-based intervention for community based patients of a specialist palliative care service living in Southern Adelaide, South Australia. Participants were 43 community living patients enrolled in the Southern Adelaide Palliative Service. To be eligible patients needed to be over 18 years and have an Australian modified Karnofksy Performance Score > 40. Exclusion criteria included a demonstrated inability to manage the hardware or technology (unless living with a carer who could manage the technology) or non-English speaking without a suitable carer/proxy. Participants received video-based conferences between service staff and the patient/carer; virtual case conferences with the patient/carer, service staff and patient’s general practitioner (GP); self-report assessment tools for patient and carer; and remote activity monitoring (ACTRN12613000733774). Results The average age of patients was 71.6 years (range: 49 to 91 years). All 43 patients managed to enter data using the telehealth system. Self-reported data entered by patients and carers did identify changes in performance status leading to changes in care. Over 4000 alerts were generated. Staff reported that videocalls were similar (22.3%) or better/much better (65.2%) than phone calls and similar (63.1%) or better/much better (27.1%) than face-to-face. Issues with the volume of alerts generated, technical support required and the impact of service change were identified. Conclusions The trial showed that patients and carers could manage the technology and provide data that would otherwise not have been available to the palliative care service. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12613000733774 registered on 02/07/2013.
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Affiliation(s)
- Jennifer J Tieman
- Palliative and Supportive Services, Flinders University, Bedford Park, South Australia, Australia.
| | - Kate Swetenham
- Southern Adelaide Palliative Services, Repatriation General Hospital, Daw Park, South Australia, Australia
| | - Deidre D Morgan
- Palliative and Supportive Services, Flinders University, Bedford Park, South Australia, Australia
| | - Timothy H To
- Southern Adelaide Palliative Services, Repatriation General Hospital, Daw Park, South Australia, Australia
| | - David C Currow
- Palliative and Supportive Services, Flinders University, Bedford Park, South Australia, Australia
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Mitchell GK, Senior HE, Bibo MP, Makoni B, Young SN, Rosenberg JP, Yates P. Evaluation of a pilot of nurse practitioner led, GP supported rural palliative care provision. BMC Palliat Care 2016; 15:93. [PMID: 27829425 PMCID: PMC5103592 DOI: 10.1186/s12904-016-0163-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 10/26/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Providing end of life care in rural areas is challenging. We evaluated in a pilot whether nurse practitioner (NP)-led care, including clinical care plans negotiated with involved health professionals including the general practitioner(GP), ± patient and/or carer, through a single multidisciplinary case conference (SMCC), could influence patient and health system outcomes. METHODS Setting - Australian rural district 50 kilometers from the nearest specialist palliative care service. PARTICIPANTS Adults nearing the end of life from any cause, life expectancy several months. Intervention- NP led assessment, then SMCC as soon as possible after referral. A clinical care plan recorded management plans for current and anticipated problems and who was responsible for each action. Eligible patients had baseline, 1 and 3 month patient-reported assessment of function, quality of life, depression and carer stress, and a clinical record audit. Interviews with key service providers assessed the utility and feasibility of the service. RESULTS Sixty-two patients were referred to the service, forty from the specialist service. Many patients required immediate treatment, prior to both the planned baseline assessment and the planned SMCC (therefore ineligible for enrollment). Only six patients were assessed per protocol, so we amended the protocol. There were 23 case conferences. Reasons for not conducting the case conference included the patient approaching death, or assessed as not having immediate problems. Pain (25 %) and depression (23 %) were the most common symptoms discussed in the case conferences. Ten new advance care plans were initiated, with most patients already having one. The NP or RN made 101 follow-up visits, 169 phone calls, and made 17 referrals to other health professionals. The NP prescribed 24 new medications and altered the dose in nine. There were 14 hospitalisations in the time frame of the project. Participants were satisfied with the service, but the service cost exceeded income from national health insurance alone. CONCLUSIONS NP-coordinated, GP supported care resulted in prompt initiation of treatment, good follow up, and a care plan where all professionals had named responsibilities. NP coordinated palliative care appears to enable more integrated care and may be effective in reducing hospitalisations.
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Affiliation(s)
- Geoffrey Keith Mitchell
- Discipline of General Practice, University of Queensland School of Medicine, Herston Rd, Herston, 4006, Queensland, Australia.
| | - Hugh Edgar Senior
- Discipline of General Practice, University of Queensland School of Medicine, Herston Rd, Herston, 4006, Queensland, Australia.,College of Health, Massey University, Auckland, New Zealand
| | - Michael Peter Bibo
- Discipline of General Practice, University of Queensland School of Medicine, Herston Rd, Herston, 4006, Queensland, Australia
| | | | - Sharleen Nicole Young
- Discipline of General Practice, University of Queensland School of Medicine, Herston Rd, Herston, 4006, Queensland, Australia.,West Moreton Hospital and Health Service, Ipswich, Australia
| | | | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, Australia
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Singer AE, Goebel JR, Kim YS, Dy SM, Ahluwalia SC, Clifford M, Dzeng E, O'Hanlon CE, Motala A, Walling AM, Goldberg J, Meeker D, Ochotorena C, Shanman R, Cui M, Lorenz KA. Populations and Interventions for Palliative and End-of-Life Care: A Systematic Review. J Palliat Med 2016; 19:995-1008. [PMID: 27533892 PMCID: PMC5011630 DOI: 10.1089/jpm.2015.0367] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2016] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Evidence supports palliative care effectiveness. Given workforce constraints and the costs of new services, payers and providers need help to prioritize their investments. They need to know which patients to target, which personnel to hire, and which services best improve outcomes. OBJECTIVE To inform how payers and providers should identify patients with "advanced illness" and the specific interventions they should implement, we reviewed the evidence to identify (1) individuals appropriate for palliative care and (2) elements of health service interventions (personnel involved, use of multidisciplinary teams, and settings of care) effective in achieving better outcomes for patients, caregivers, and the healthcare system. EVIDENCE REVIEW Systematic searches of MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Database of Systematic Reviews databases (1/1/2001-1/8/2015). RESULTS Randomized controlled trials (124) met inclusion criteria. The majority of studies in cancer (49%, 38 of 77 studies) demonstrated statistically significant patient or caregiver outcomes (e.g., p < 0.05), as did those in congestive heart failure (CHF) (62%, 13 of 21), chronic obstructive pulmonary disease (COPD; 58%, 11 of 19), and dementia (60%, 15 of 25). Most prognostic criteria used clinicians' judgment (73%, 22 of 30). Most interventions included a nurse (70%, 69 of 98), and many were nurse-only (39%, 27 of 69). Social workers were well represented, and home-based approaches were common (56%, 70 of 124). Home interventions with visits were more effective than those without (64%, 28 of 44; vs. 46%, 12 of 26). Interventions improved communication and care planning (70%, 12 of 18), psychosocial health (36%, 12 of 33, for depressive symptoms; 41%, 9 of 22, for anxiety), and patient (40%, 8 of 20) and caregiver experiences (63%, 5 of 8). Many interventions reduced hospital use (65%, 11 of 17), but most other economic outcomes, including costs, were poorly characterized. Palliative care teams did not reliably lower healthcare costs (20%, 2 of 10). CONCLUSIONS Palliative care improves cancer, CHF, COPD, and dementia outcomes. Effective models include nurses, social workers, and home-based components, and a focus on communication, psychosocial support, and the patient or caregiver experience. High-quality research on intervention costs and cost outcomes in palliative care is limited.
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Affiliation(s)
- Adam E. Singer
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
- RAND Corporation, Santa Monica, California
| | - Joy R. Goebel
- School of Nursing, California State University, Long Beach, Long Beach, California
| | - Yan S. Kim
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sydney M. Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Elizabeth Dzeng
- Division of Hospital Medicine, University of California at San Francisco, San Francisco, California
| | - Claire E. O'Hanlon
- RAND Corporation, Santa Monica, California
- Pardee RAND Graduate School, RAND Corporation, Santa Monica, California
| | | | - Anne M. Walling
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
- RAND Corporation, Santa Monica, California
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Jaime Goldberg
- Supportive Care Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniella Meeker
- Department of Preventive Medicine, University of Southern California, Los Angeles, California
| | | | | | - Mike Cui
- RAND Corporation, Pittsburgh, Pennsylvania
| | - Karl A. Lorenz
- RAND Corporation, Santa Monica, California
- Stanford University School of Medicine, Stanford, California
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47
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Dhingra L, Dieckmann NF, Knotkova H, Chen J, Riggs A, Breuer B, Hiney B, Lee B, McCarthy M, Portenoy R. A High-Touch Model of Community-Based Specialist Palliative Care: Latent Class Analysis Identifies Distinct Patient Subgroups. J Pain Symptom Manage 2016; 52:178-86. [PMID: 27208864 DOI: 10.1016/j.jpainsymman.2016.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/08/2016] [Accepted: 04/27/2016] [Indexed: 11/24/2022]
Abstract
CONTEXT Community-based palliative care may support seriously ill homebound patients. Programs vary widely, and few studies have described the heterogeneity of the populations served or service delivery models. OBJECTIVES To evaluate a diverse population served by an interdisciplinary model of community-based specialist palliative care and the variation in service delivery over time and identify subgroups with distinct illness burden profiles. METHODS A retrospective cohort study evaluated longitudinal electronic health record data from 894 patients served during 2010-2013. Illness burden was defined by measures of performance status (Karnofsky Performance Status scale), symptom distress (Condensed Memorial Symptom Assessment Scale), palliative care needs (Palliative Outcome Scale), and quality of life (Spitzer Quality of Life Index). Service utilization included the frequency of visits received and calls made or received by patients. Latent class analysis identified patient subgroups with distinct illness burden profiles, and mixed-effects modeling was used to evaluate associations between patient characteristics and service utilization. RESULTS The mean age was 72.3 years (SD = 14.0); 56.2% were women; 67.5% were English speaking; and 22.2% were Spanish speaking. Most had congestive heart failure (36.4%) or cancer (30.4%); 98.0% had a Karnofsky Performance Status score of 40-70. Four patient subgroups were identified: very low illness burden (26.2%); low burden (39.5%); moderate burden (13.5%); and high burden (20.8%). The subgroups differed in both baseline characteristics and palliative care service utilization over time. CONCLUSION The population served by a community-based specialist palliative care program manages patients with different levels of illness burden, which are associated with patient characteristics and service utilization.
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Affiliation(s)
- Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA.
| | - Nathan F Dieckmann
- School of Nursing and School of Medicine, Oregon Health & Science University, Portland, Oregon, USA; Decision Research, Eugene, Oregon, USA
| | - Helena Knotkova
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jack Chen
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Alexa Riggs
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Brenda Breuer
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Barbara Hiney
- MJHS Hospice and Palliative Care, New York, New York, USA
| | - Bernard Lee
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Maureen McCarthy
- The Center for Hospice & Palliative Care, New York, New York, USA
| | - Russell Portenoy
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, USA; MJHS Hospice and Palliative Care, New York, New York, USA
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Ekström M, Vergo MT, Ahmadi Z, Currow DC. Prevalence of Sudden Death in Palliative Care: Data From the Australian Palliative Care Outcomes Collaboration. J Pain Symptom Manage 2016; 52:221-7. [PMID: 27220950 DOI: 10.1016/j.jpainsymman.2016.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 01/20/2016] [Accepted: 02/13/2016] [Indexed: 10/21/2022]
Abstract
CONTEXT Advanced, life-limiting illnesses are likely to have a predictable functional decline through a terminal phase to death, but some patients may also die suddenly. To date, empirical evidence characterizing "sudden death" in hospice/palliative care is lacking. OBJECTIVES The aim of this study was to determine prevalence and clinicodemographic predictors of sudden death in hospice/palliative care. METHODS This is a longitudinal consecutive cohort study of prospectively collected national data in 104 specialist palliative care services from the Australian Palliative Care Outcomes Collaboration. Patients who died between July 1, 2013, and June 30, 2014, with one or more measurement of Australian-modified Karnofsky Performance Status (AKPS) in the last 30 days of life were included. "Sudden death" was defined as a lowest AKPS score of 50 or more in the last seven days of life and excluded anyone with "terminal phase" as their last phase before death. Predictors were defined using logistic regression. RESULTS In total, 13,966 patients were included, mean age 73.6 (SD 13.6) years, 46% women, and 77% had cancer. During the seven days before death, there were 20,992 AKPS measurements; median 1 (interquartile range 1-2) per patient. Four percent of deaths (one of 25) were sudden, predicted independently by having lung cancer (odds ratio [OR] 2.64), cardiovascular disease (OR 1.94), other cancers (OR 1.63), being male (OR 1.23), younger, worse fatigue, and worse breathlessness. Sudden death was associated with higher rates of death at home (OR 3.2; 95% CI 2.9 to 3.6). CONCLUSION This study quantifies rates of sudden death in hospice/palliative care and has implications for conversations about prognosis between clinicians, patients, and their families.
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Affiliation(s)
- Magnus Ekström
- Division of Respiratory Medicine and Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden; Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia.
| | - Maxwell T Vergo
- Palliative Medicine and Hospice Care, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Zainab Ahmadi
- Division of Respiratory Medicine and Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia; Palliative Medicine and Hospice Care, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Health service use and costs in the last 6 months of life in elderly decedents with a history of cancer: a comprehensive analysis from a health payer perspective. Br J Cancer 2016; 114:1293-302. [PMID: 27115468 PMCID: PMC4891509 DOI: 10.1038/bjc.2016.75] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 11/27/2015] [Accepted: 12/04/2015] [Indexed: 01/02/2023] Open
Abstract
Background: There is growing interest in end-of-life care in cancer patients. We aim to characterise health service use and costs in decedents with cancer history and examine factors associated with resource use and costs at life's end. Methods: We used routinely collected claims data to quantify health service use and associated costs in two cohorts of elderly Australians diagnosed with cancer: one cohort died from cancer (n=4271) and the other from non-cancer causes (n=3072). We used negative binomial regression to examine the factors associated with these outcomes. Results: Those who died from cancer had significantly higher rates of hospitalisations and medicine use but lower rates of emergency department use than those who died from non-cancer causes. Overall health care costs were significantly higher in those who died from cancer than those dying from other causes; and 40% of costs were expended in the last month of life. Conclusions: We analysed health services use and costs from a payer perspective, and highlight important differences in patterns of care by cause of death in patients with a cancer history. In particular, there are growing numbers of highly complex patients approaching the end of life and the heterogeneity of these populations may present challenges for effective health service delivery.
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Agar M, Beattie E, Luckett T, Phillips J, Luscombe G, Goodall S, Mitchell G, Pond D, Davidson PM, Chenoweth L. Pragmatic cluster randomised controlled trial of facilitated family case conferencing compared with usual care for improving end of life care and outcomes in nursing home residents with advanced dementia and their families: the IDEAL study protocol. BMC Palliat Care 2015; 14:63. [PMID: 26589957 PMCID: PMC4654825 DOI: 10.1186/s12904-015-0061-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 11/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Care for people with advanced dementia requires a palliative approach targeted to the illness trajectory and tailored to individual needs. However, care in nursing homes is often compromised by poor communication and limited staff expertise. This paper reports the protocol for the IDEAL Project, which aims to: 1) compare the efficacy of a facilitated approach to family case conferencing with usual care; 2) provide insights into nursing home- and staff-related processes influencing the implementation and sustainability of case conferencing; and 3) evaluate cost-effectiveness. DESIGN/METHODS A pragmatic parallel cluster randomised controlled trial design will be used. Twenty Australian nursing homes will be randomised to receive either facilitated family case conferencing or usual care. In the intervention arm, we will train registered nurses at each nursing home to work as Palliative Care Planning Coordinators (PCPCs) 16 h per week over 18 months. The PCPCs' role will be to: 1) use evidence-based 'triggers' to identify optimal time-points for case conferencing; 2) organise, facilitate and document case conferences with optimal involvement from family, multi-disciplinary nursing home staff and community health professionals; 3) develop and oversee implementation of palliative care plans; and 4) train other staff in person-centred palliative care. The primary endpoint will be symptom management, comfort and satisfaction with care at the end of life as rated by bereaved family members on the End of Life in Dementia (EOLD) Scales. Secondary outcomes will include resident quality of life (Quality of Life in Late-stage Dementia [QUALID]), whether a palliative approach is taken (e.g. hospitalisations, non-palliative medical treatments), staff attitudes and knowledge (Palliative Care for Advanced Dementia [qPAD]), and cost effectiveness. Processes and factors influencing implementation, outcomes and sustainability will be explored statistically via analysis of intervention 'dose' and qualitatively via semi-structured interviews. The pragmatic design and complex nature of the intervention will limit blinding and internal validity but support external validity. DISCUSSION The IDEAL Project will make an important contribution to the evidence base for dementia-specific case conferencing in nursing homes by considering processes and contextual factors as well as overall efficacy. Its strengths and weaknesses will both lie in its pragmatic design. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12612001164886. Registered 02/11/2012.
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Affiliation(s)
- Meera Agar
- Discipline of Palliative and Supportive Services, Flinders University, Adelaide, Australia.
- South West Sydney Clinical School, and Improving Palliative Care through Clinical trials (ImPACCT), University of New South Wales, Sydney, Australia.
- Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, Australia.
- Ingham Institute of Applied Medical Research, Sydney, Australia.
| | - Elizabeth Beattie
- Dementia Collaborative Research Centre, Queensland University of Technology, Brisbane, Australia.
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Australia.
| | - Tim Luckett
- South West Sydney Clinical School, and Improving Palliative Care through Clinical trials (ImPACCT), University of New South Wales, Sydney, Australia.
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, Australia.
- University of Technology Sydney (UTS) Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia.
| | - Jane Phillips
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, Australia.
| | - Georgina Luscombe
- School of Rural Health, Faculty of Medicine, The University of Sydney, Sydney, Australia.
| | - Stephen Goodall
- Centre for health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, Australia.
| | - Geoffrey Mitchell
- Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Australia.
| | - Dimity Pond
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, Newcastle, Australia.
| | | | - Lynnette Chenoweth
- Faculty of Health, University of Technology Sydney, Sydney, Australia.
- Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia.
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